Contact | Q & A | Topic | Free Ad    




Massage Therapist Assessment
This template can be customized to your massage practice so that each therapist may be informed of certain personal facts about your clients before performing any type of massage on them. Knowing this personal and medical information can help improve the experience of your customer while making sure that communication is consistent between massage therapists.

Free Sample Template
Format: Word PDF
# of Pages: 2
Printable: Yes

Massage Therapist Assessment TemplateForm 2716
Format: Word PDF
Category: Occupation, Massage
Type: Assessment

Massage Assessment Form

Full Name: ____________________________________________________________________________________

Address: ______________________________________________________________________________________

City: ______________________________________________ State: ________ Zip Code: _____________________

Phone Number: ________________________________________________________________________________

Email Address: _________________________________________________________________________________

Date of Birth: ___/___/_____ Occupation: ___________________________________________________________

Emergency Contact: _____________________________________________________________________________

Emergency Phone Number: _____________________________________ Relationship: ______________________

Referred by: ___________________________________________________________________________________

Have you had a professional massage before? ___ Yes ___ No If yes, how frequently do you get a massage? ______

_____________________________________________________________________________________________

What are your expectations for today’s massage session? ______________________________________________

_____________________________________________________________________________________________

Are you aware of any spots on your body that are holding tension? _______________________________________

_____________________________________________________________________________________________

Please list any hospitalizations, accidents and or injuries that you have had: ________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Do you have any chronic and ongoing pain that you deal with on a regular basis? ___________________________

_____________________________________________________________________________________________

What activities cause this pain and or make it worse? __________________________________________________

_____________________________________________________________________________________________

Are you receiving any other type of medical treatment? ________________________________________________




_____________________________________________________________________________________________

What type of medications are you presently taking? ___________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Are you currently under the care of a physician? ___ Yes ___ No If yes, please list physician and the reason for

treatment: ____________________________________________________________________________________

_____________________________________________________________________________________________

Please list any other health concerns that you would like to discuss today? ________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________