Massage Therapy Client Intake Form

Preferred Language / Idioma Preferido

¿Prefiere completar este formulario en español?

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Full Name

First Name Last Name

Birth Date

MonthDayYear

Zip Code

Street Address

Street Address Line 2 (apartment number, unit number)

Zip Code

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Format: (000) 000-0000.

Occupation (optional)

What type of massage are you looking for today?

If you have selected post-operative lymphatic massage, please abandon this form and open Post-Operative Lymphatic Masssage Intake Form and complete that form. Thank you!

If you have selected prenatal massage, please abandon this form, and complete the Prenatal Massage Intake Form. Thank you!

What brings you in for a massage today?

What pressure do you prefer?

You can ask your therapist to adjust the pressure at any time.

1. Where are you experiencing discomfort or tension?

2. Have you ever injured this area before?

Please describe the injury, when it occurred, and whether you still experience pain or limited movement.

3. How long have you been experiencing pain or discomfort?

5. How often do you experience pain or discomfort?

4. Rate of Pain Today

6. What makes your pain or discomfort better or worse?

7. Are you currently seeing any other healthcare professional?

Do you currently have or have you ever been diagnosed with any of the following medical conditions? Select all that apply.

Have you ever had any surgeries or medical procedures?

Please describe the surgery or procedure, the date it was performed, and the area of the body affected.

Do you have any allergies or sensitivities to medications, latex, oils, lotions, fragrances and other relevant sensitivities.

Please list any medications you currently take, including prescription medications and over-the-counter medications. If none, write “None.”

Massage Policies and Client Agreement

Massage Policies

Confidentiality

Your personal and health information is confidential and will not be shared without your written consent, except as permitted or required by law.

Cell Phones

Please silence or turn off your cell phone during your appointment to help maintain a calm and relaxing environment.

Arrival and Tardiness

Please arrive on time for your appointment. If you arrive more than 10 minutes late, we may need to reschedule your session, depending on availability. The full length of your service cannot be guaranteed if you are late.

Cancellations and Rescheduling

A minimum of 24 hours' notice is required to cancel or reschedule an appointment to avoid losing your deposit. If you reschedule, your deposit may be transferred to one future appointment.

Draping and Privacy

You may undress in private to the level that feels comfortable for you. Please lie between the sheets to begin your session. Proper draping will be maintained throughout the massage to protect your privacy and comfort.

Consultation and Preparation

Before your session, your therapist will discuss your needs, goals, and any areas of concern so the massage can be tailored to your preferences.

Right to End a Session

You or your massage therapist may end the session at any time and for any reason.

Professional Boundaries

No inappropriate, abusive, or sexual behavior will be tolerated. Such behavior will result in immediate termination of the session and may be reported to the appropriate authorities.

Client Agreement

Scope of Practice

Massage therapists do not diagnose medical, physical, or mental conditions; do not prescribe medical treatments or medications; and do not perform joint mobilizations outside the authorized scope of practice.

Medical Care and Clearance

Massage therapy is not a substitute for medical examination, diagnosis, or treatment. Depending on your health status, you may need to consult a healthcare professional before receiving massage. To receive massage after surgery, you must obtain clearance from your surgeon or treating healthcare provider before your session and follow any instructions or restrictions provided.

Voluntary Consent and Expected Benefits

Receiving massage therapy is your choice. Massage may help address muscle tension, discomfort, pain, or myofascial dysfunction; however, results vary and specific outcomes are not guaranteed.

Possible Risks and Side Effects

Massage may cause temporary muscle soreness, tenderness, increased sensitivity, or other mild discomfort after the session. Reactions vary from person to person. Please inform your massage therapist of any pain, discomfort, unusual sensations, or concerns during the session so adjustments can be made as needed. Massage may not be appropriate for all health conditions, and your session may be modified, postponed, or declined when necessary for safety reasons.

Communication During Treatment

Please communicate any pain, discomfort, changes in sensation, or concerns during your session so your massage therapist can adjust pressure or technique as needed.

Health Information

You confirm that the health information you provide, including medical conditions, medications, allergies, surgeries, and any other relevant information, is accurate and complete to the best of your knowledge. You agree to inform your massage therapist of any changes in your health status before future sessions.

Acknowledgment and Consent

By signing electronically, you confirm that you have read and understood these Massage Policies and Client Agreement, that you have had the opportunity to ask questions, and that you voluntarily agree to these terms and consent to receive massage therapy.

This is my massage therapy intake. Can you tweak it where needed to do the prenatal policies and consent

Date

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Client Intake Form

Pain and Muscle Tension History

Medical History