Massage Therapy Client Intake Form
ADVERTISEMENT
1
2Massage Therapy Client Intake Form
The following information will be used to help plan safe and effective massage sessions.
Please answer the questions to the best of your knowledge.
Personal Information
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
5. Are you wearing
contact lenses
dentures
hearing aids ?
6. Do you sit for long hours at a workstation, computer, or driving?
Yes
No
If yes, please describe _____________________________________________________________________
7. Do you perform any repetitive movement in your work, sports, or hobby?
Yes
No
If yes, please describe _____________________________________________________________________
8. Do you experience stress in your work, family, or other aspect of your life?
Yes
No
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
No
If yes, please identify ______________________________________________________________________
10. Do you have any particular goals in mind for this massage session?
Yes
No
If yes, please explain ______________________________________________________________________
Circle any specific areas you would like
the massage therapist to concentrate
on during the session:
208 Washington Street | Jersey City, New Jersey 07302 | 201-333-FACE
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business