Massage Intake Form
Personal Information
Name ________________________________________ Phone (day) _____________________ (evening) _____________________
Address _____________________________________ City/State/Zip _________________________________ DOB ___________
Occupation _____________________________________________ Employer ___________________________________________
Email _______________________________________________ Primary Physician _______________________________________
Emergency Contact ____________________________________ Relationship __________________ Phone __________________
How did you hear about us? ____________________________________________________________________________________
Medical Information Massage Information
Are you taking any medications? yes no Have you had a professional massage before? yes no
If yes, please list name and use: _____________________ What type of massage are you seeking?
_______________________________________________ Relaxation Therapeutic/Deep Tissue
Are you currently pregnant? yes no Other ___________________________________________
If yes, how far along? ______________________________ What pressure do you prefer?
Any high risk factors? ______________________________ Light Medium Deep
Do you suffer from chronic pain? yes no Do you have any allergies or sensitivities? yes no
If yes, please explain ______________________________ Please explain ________________________________
What makes it better? _____________________________ Are there any areas (feet, face, abdomen, etc.) you do not
_______________________________________________ want massaged? yes no
Please explain _______________________________
What makes it worse? ____________________________
What are your goals for this treatment session?
_______________________________________________
_____________________________________________
Have you had any orthopedic injuries? yes no
Please circle any areas of discomfort
If yes, please list: ________________________________
Please indicate any of the following that apply to you.
Cancer Fibromyalgia
Headaches/Migraines Stroke
Arthritis Heart Attack
Diabetes Kidney Dysfunction
Joint Replacement(s) Blood Clots
High/Low Blood Pressure Numbness
Neuropathy Sprains or Strains
By signing below, you agree to the following.
Explain any conditions you have marked above: 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 any time.
________________________________________________
________________________________________________ Client Signature __________________________ Date __________
________________________________________________ Therapist Signature _______________________ Date __________
