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Massage Intake Form
When a new client begins services please have them take the time to complete the following intake form. By providing their past history along medical background the massage therapist providing services will be able to provide appropriate care. Additionally make sure the client signs the form as there is an agreement regarding services entered when they complete the form. Place the completed intake form in the client file for the massage therapist.

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

Massage Intake Form TemplateForm 2701
Format: Word PDF
Category: Occupation, Massage
Type: Form

Massage Intake Form

Name: ______________________________________________________________________ DOB: ___/___/_____

Address: ______________________________________________________________________________________

City: __________________________________________ State: __________ Zip Code: _______________________

Phone Number: ________________________________________________________________________________

Email Address: _________________________________________________________________________________

Occupation: ___________________________________________________________________________________

Have you ever received massage therapy before? ___ Yes ___No

If yes, what type of massage therapy? ______________________________________________________________

Are you currently taking any medications? ___ Yes ___ No

If yes, please list the medications you are taking and the reason why: _____________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Are you currently seeing a healthcare professional? ___ Yes ___ No

If yes, please list the names and reason for treatment: _________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please review the following list and mark the conditions that you have a history of either recently or in the past.

Arthritis

Auto-Immune Condition

Depression

Muscle Strain/Sprain

Diabetes

Hepatitis(A, B, C, other)

Diverticulitis

Pregnancy

Broken or Dislocated Bones

Skin Conditions

Headaches

Scoliosis

Bruise Easily

Stroke

Heart Condition

Seizures

Cancer

Surgery

Back Problems

Whiplash

Chronic Pain

TMJ Disorder

High Blood Pressure

Chemical Dependency

Constipation

Other:

Insomnia




Do you have any of the following presently:

___ Skin Rash ___ Cold / Flu ___ Open Cuts ___ Severe Pain ___ Anything Contagious __Injuries/Bruises

Do you have any allergies to:

__ Medications ___ Foods ___ Environmental Allergens ___ Reactions to Skin Care Products

If any of the above are checked please provide details: _________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Are you wearing: ___ Contact Lenses ___ Hearing Aid ___ Hairpiece

What are your goals / expectations for this therapy session? ____________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

1. I understand that massage therapy can be very therapeutic, relaxing and reduce muscle tension, it is not a substitute for medical examination, diagnosis and treatment by a physician.

2. This is strictly a therapeutic massage and any remarks or advances that are sexual in nature will terminate the session and I will be held liable for the payment of the scheduled treatment.

3. Massage should not be done under certain medical conditions, I hereby affirm that I have answered all of the above questions that pertain to my medical condition truthfully.

Signature: ___________________________________________________________________ Date: ___/___/_____