Massage Therapy Intake Form

Client Information

First Name *

Last Name *

Phone Number *

Email *

Birth Date *

Street Address

City

State

Zip Code

Emergency Contact & Referral

Emergency Contact Name *

Emergency Contact Phone *

How did you hear about us?

Issues to Address

Please mark any areas of pain, tension, or discomfort on the diagrams below.

Please describe the sensations (e.g., sharp, dull, aching, tingling)

Health History

Please check all conditions that apply and elaborate where necessary.

Cardiovascular

High Blood Pressure

Blood Clots

Cold Hands/Feet

Stroke

Heart Attack

Heart Disease

Elaboration on Cardiovascular items:

Neurological

Numbness/Tingling

Migraines/Headaches

Herniated Disc

Multiple Sclerosis

Dizziness

Elaboration on Neurological items:

Medications & Surgeries

Current Medications (Prescription & Over-the-counter)

Previous Surgeries (Please list with approximate dates)

Allergies (Medications, lotions, environment, etc.)

Consent & Signature

Client Waiver & Consent

I understand that massage therapy is for the purpose of general wellness, relaxation, and relief of muscular tension.
I acknowledge that massage therapy is not a substitute for medical examination, diagnosis, or treatment.
I have disclosed all relevant medical conditions and will inform the therapist of any changes in my health status.
I understand that I may end the session at any time for any reason.
I acknowledge that all services are therapeutic and non-sexual, and that inappropriate behavior will result in immediate termination of the session.

Digital Signature *

I have read and agree to the policies above.

Client Intake Form