KMM Client Intake Form

Kentuckiana Mobile Massage Client Intake Form

Please complete this form to help us provide the safest and most effective massage therapy session for you.
Client Information
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Occupation
Referred by
Health Information
Are you taking any medications?
If yes, please list medications
Do you have any allergies? (oils, lotions, nuts, fruits, skin, etc.)
If yes, please list allergies
Are you pregnant?
If pregnant, how many months?
Due date (if pregnant)

MonthDayYear
Date
Are you currently under medical supervision or receiving other medical interventions?
If yes, please describe medical supervision/interventions
Please indicate if you have any of the following conditions:
Areas of broken skin? (e.g. rash, wounds)
If yes, where?
History of joint replacement surgery?
Which joint(s)?
Recent injuries or medical procedures in the past 2 years?
If yes, please describe
Please describe any other injuries or health conditions
Massage Information
Have you had professional massage before?
How recently was your last massage?
Reason for seeking massage
If specific problem, please describe
How much pressure do you prefer?
Signatures
Client Signature
Client Signature Date

MonthDayYear
Date
Therapist Signature
Therapist Signature Date

MonthDayYear
Date
Should be Empty:

Kentuckiana Mobile Massage Client Intake Form