Massage Intake Form

Client Name *

First

Last

Layout

Date of Birth *

Email *

Phone *

Address *

Layout

Occupation

Employer

Primary Physician

Emergency Contact Name *

First

Last

Relationship *

Emergency Contact Phone *

Please read and complete this form carefully.

By completing this form, you declare that the answers given herein are true and complete to the best of your knowledge. False or misleading answers can lead to complications and/or undesirable results.

Please indicate your answer by selecting per question and provide detail where appropriate.

Are you taking any medications? *

Yes
No

Are you currently pregnant? *

Yes
No

Do you Suffer from chronic pain? *

Yes
No

Have you had any orthopedic injuries? *

Yes
No

Explain any conditions you have marked above:

Have you had a professional massage before? *

Yes
No

What type of massage are you seeking? *

Relaxation
Therapeutic/Deep Tissue
Other

What type of pressure do you prefer? *

Light
Medium
Deep

Do you have any allergies or sensitivities? *

Yes
No

Are there any areas (Feet, face, abdomen, etc.) you do not want massaged? *

Yes
No

What are your goals for this treatment session? *

Please list any areas in which you feel discomfort. *

By signing below, you agree to thef ollowing. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at anytime.

Client Signature *

Date *

Send me a copy.

Location

Contact