Client Intake Form - Massage Therapy printable pdf download

Client Intake Form - Massage Therapy

12500 W. 58

Ave., Unit 102, Arvada, CO 80002

Client Intake Form—Massage Therapy

Name:____________________________________________________________________

Address:_______________________________________ City:________________ State:_____ Zip: _______

Cell Phone:_______________________

Alt Phone: ____________________________

Email:______________________________________

Occupation:__________________________________

Birthday:____________________

Emergency Contact:_____________________________________

Relationship:_____________________________ Phone:___________________________

The following information will be used to help your massage therapist plan a safe and effective massage

session. Please answer the questions to the best of your knowledge.

Have you had a professional massage before? Y / N If so, when was your last treatment?_____________

Is there a specific area of the body where you are experiencing tension, stiffness, pain, or discomfort?

_________________________________________________________________________________________

If you are dealing with any chronic pain, illness, or disability, please describe:

_________________________________________________________________________________________

Are you currently taking any medication (including self-prescribed)? If so, please explain:

__________________________________________________________________________________________

Are you wearing __ contact lenses __ dentures __a hearing aid __prosthetics?

Do you perform any repetitive movement in your work, sports, or hobbies? ____________________________

_________________________________________________________________________________________

Do you have sensitive skin? Y / N

Are you pregnant? Y / N

If so, how many months?__________________

Client Intake Form - Massage Therapy