Therapeutic Massage - Client Intake Form
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1Therapeutic Massage – Client Intake Form
Personal Information
Name ____________________________________ Phone (day) _____________________ (evening) _______________________
Address __________________________________ City, State, Zip __________________________________________________
Email (optional) ____________________________ Date of Birth __________________ Occupation _______________________
Emergency Contact _________________________ Phone _____________________
Physician _________________________________ Phone _____________________
Massage Information
Medical History
How did you hear about us? ________________________________
Do you suffer from chronic or persistent pain/discomfort?
Have you ever had a professional massage before? □ yes □ no
_______________________________________________
If yes, how often to you receive massage therapy? ______________
If so, for how long? ______________________________
If yes, do you have a style or pressure preference? □ yes □ no
Do you know what caused it or when then symptoms seem
Specify : □ light pressure □ medium pressure □ deep pressure
to get worse or better? ____________________________
□ trigger point therapy □ energywork
_______________________________________________
□ Other ___________________________
Do you see a chiropractor? □ yes □ no
What Type of massage are you seeking today?
If so, how often? __________________________________
□ Relaxation □ Deep Tissue/Therapeutic □ Pregnancy
Are you currently under medical care? □ yes □ no
□ Senior □ Integrated Bodywork (functional)
Are you currently taking any prescription medication? If
□ Other ________________________
so, for what? _____________________________________
Are you sensitive to fragrances or perfumes? □ yes □ no
________________________________________________
Do you have sensitive skin? □ yes □ no
________________________________________________
Do you wear contact lenses? □ yes □ no
Please indicate any conditions that you have had or
Do you exercise regularly?
□ yes □ no
currently have:
If so, what type(s)? _______________________________________
□ headaches, migraines
□ varicose veins
□ allergies, sensitivity
□ pregnancy
What are your common areas of pain or tension?
□ arthritis, tendonitis
□ blood clots
_______________________________________________________
□ cancer, tumors
□ neck / back injuries
_______________________________________________________
□ TMJ problems
□ diabetes
Circle any specific areas you would like the massage therapist to
□ abnormal skin condition
□ paralysis
concentrate on during the session:
□ heart/circulation problems
□ fibromyalgia
□ joint replacement / surgery
□ numbness
□ high / low blood pressure
□ sprains, strains
□ major accident
□ recent injuries
□ lack of or reduced feeling / sensation _______________
Explain any conditions that you have marked above:
________________________________________________
________________________________________________
________________________________________________
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