Massage Therapy Client Intake Form printable pdf download

Massage Therapy Client Intake Form

Name___________________________________________________________ Date_____________________

Address___________________________________________________________________________________

Street

City

State

Zip

Date of Birth______________ Home Number ___________________ Cell Number______________________

Emergency Contact _________________________________________________________________________

Name

Relationship

Number

Are you presently taking any medication? __________Yes ____________No

Please Explain:

Have you had a recent major surgical procedure or injury? ____ Yes ____ No

Please Explain:

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?

____ Yes ____No

Please Explain:

Please circle your stress level:

Low 1 2 3 4 5 High

Are you allergic to any Lotions or Oils? ____ Yes ____ No

Please Explain:______________________________________________________

Note: I use Biotone Hypoallergenic Sensitive Skin Lotions and Oils. These are also scent free.

Massage Therapy Client Intake Form