Massage Therapy Client Intake Form printable pdf download

Sedona Healing Arts

Massage Therapy Client Intake Form

Client Intake Form – Therapeutic Massage

Personal Information:

Name: ____________________________________________________________

Home Phone:_______________________________________________________

Mobile Phone:______________________________________________________

Address:___________________________________________________________

City/State/Zip:______________________________________________________

Email:_____________________________ Date of Birth:____/_____/______

Occupation:____________________________________________

Emergency Contact Phone:__________________________

Thank you for choosing Sedona Healing Arts. We welcome you to our practice and are happy you have chosen

our massage therapy services. The therapist here are licensed, insured and nationally certified. Conservative

draping will be used during the session – only the area being worked on will be uncovered.

Male and female genitalia will not be exposed at anytime during the treatment, in addition under no

circumstances do we massage any male or female genitalia. If you feel uncomfortable during the session, or

need to end the session, please let your therapist know and the session will be ended immediately.

Your privacy is our top priority, as a provider of complimentary alternative health we uphold and abide by the

HIPAA laws and do not share or release any of your information unless we have a written statement from you or

a subpoena from the courts.

Below you will find questions concerning your health history. It is your responsibility to inform your therapist

of any pre-existing conditions, mobility limitations or discomfort during your session.

The following information will be used to help plan safe and effective massage sessions.

Please answer the questions to the best of your knowledge.

1. Have you had a professional massage before? □Yes

□ No

If yes, how often do you receive massage therapy?_________________________________________________

2. Do you have any difficulty lying on your front, back, or side? □Yes

□ No

If yes, please explain_________________________________________________________________________

3. Do you have any allergies to oils, lotions, or ointments? □Yes

□ No

If yes, please explain_________________________________________________________________________

4. Do you have sensitive skin?

□Yes

□ No

□Yes

□ No

5. Do you experience stress in your work, family, or other aspect of your life?

If yes, how do you think it has affected your health?________________________________________________

muscle tension □ anxiety □ insomnia □ irritability □ exasperates other health conditions □ other □

6. Do you have any particular goals in mind for this massage session? □Yes □ No

If yes, please explain? __________________________________________________________________

Massage Therapy Client Intake Form