Client Intake Form - Therapeutic Massage printable pdf download

Client Intake Form – Therapeutic Massage

Personal Information:

Name _____________________________ Phone ____________________ Date of Birth ________________

Address ______________________________________ City _____________ State ________ Zip __________

E-mail ______________________________________________ Occupation ___________________________

Emergency Contact _________________________ Phone _________________Relationship ______________

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

Please answer the questions to the best of your knowledge.

Date of Initial Visit _________________________________________________________________________

1. Have you had a professional massage before?

Yes

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

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

Yes

If yes, please explain _________________________________________________________________________________________

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

Yes

If yes, please explain _________________________________________________________________________________________

4. Do you have sensitive skin?

Yes

5. Are you wearing contact lenses ( ) dentures ( ) a hearing aid ( )?

6. Do you sit for long hours at a workstation, computer, or driving?

Yes

If yes, please describe ________________________________________________________________________________________

7. Do you perform any repetitive movement in your work, sports, or hobby?

Yes

If yes, please describe ________________________________________________________________________________________

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

Yes

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

Muscle tension

anxiety

insomnia

irritability

Other __________________________________

9. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?

Yes

If yes, please identify _________________________________________________________________________________________

10. Do you have any particular goals in mind for this massage session?

Yes

If yes, please explain _________________________________________________________________________________________

Circle any specific areas you would like the massage

therapist to concentrate on during the session:

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Client Intake Form - Therapeutic Massage