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    Massage Intake Form

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    api-263560654
    This massage client intake form collects information such as the client's name, contact details, medical history, areas of concern, medication, and allergies. It notes whether the client has received massage before and their reason for visiting. The client indicates their preferred pressure level and any areas to avoid. They confirm whether they have any medical conditions or are under a doctor's care. The form states that the massage is for therapeutic purposes only and does not replace medical care. It collects an emergency contact and has the client sign.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Massage Intake Form

    Uploaded by

    api-263560654
    109 views2 pages
    This massage client intake form collects information such as the client's name, contact details, medical history, areas of concern, medication, and allergies. It notes whether the client has received massage before and their reason for visiting. The client indicates their preferred pressure level and any areas to avoid. They confirm whether they have any medical conditions or are under a doctor's care. The form states that the massage is for therapeutic purposes only and does not replace medical care. It collects an emergency contact and has the client sign.

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    massage intake form

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    This massage client intake form collects information such as the client's name, contact details, medical history, areas of concern, medication, and allergies. It notes whether the client has received massage before and their reason for visiting. The client indicates their preferred pressure level and any areas to avoid. They confirm whether they have any medical conditions or are under a doctor's care. The form states that the massage is for therapeutic purposes only and does not replace medical care. It collects an emergency contact and has the client sign.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    109 views2 pages

    Massage Intake Form

    Uploaded by

    api-263560654
    This massage client intake form collects information such as the client's name, contact details, medical history, areas of concern, medication, and allergies. It notes whether the client has received massage before and their reason for visiting. The client indicates their preferred pressure level and any areas to avoid. They confirm whether they have any medical conditions or are under a doctor's care. The form states that the massage is for therapeutic purposes only and does not replace medical care. It collects an emergency contact and has the client sign.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Healing Hands Therapeutic Massage

    Massage Client Intake Form


    Name_____________________________________Nickname_____________________________________
    Address___________________________________City_____________________State____Zip__________
    E-Mail___________________________________ Alternate E-Mail_______________________________
    Primary Phone #____________________________Cell_________________________________________
    Birth Date___________________Occupation_________________________________________________
    Have you ever received a professional massage? Yes___ No___
    If yes, how often and what type of massage?____________________________________________
    Did someone refer you? Yes__ No__ If yes, who?________________________________________________
    What is the reason for your visit today?_________________________________________________________
    Are there any areas you would like me to spend more time on? Yes___ No___
    If yes, what are some areas?__________________________________________________________
    How much pressure do you like? Light___ Deep___ Very Deep___
    Are there any areas you would like to avoid being treated? Yes___ No___
    If yes, please indicate the area(s) to avoid________________________________________________
    Are you under the care of a physician or other health practitioner? Yes___ No___
    If yes, for what?_____________________________________________________________________
    Do you have any problems that I should know about?________________________________________________
    If yes, do you have a doctors consent to receive massage? Yes___ No___
    Are you pregnant? Yes___ No___ If yes, circle current trimester 1 2 3
    List any medication you are currently taking and what they are for:

    List any know allergies:__________________________________________________________


    Please check any of the following conditions or symptoms you have or have had:
    ___Serious Injury
    ___Blood Clots
    ___Allergies
    ___High/low Blood Pressure
    ___Cancer
    ___AIDS
    ___Stroke
    ___Headaches/migraines
    ___Skin Infections
    ___Contagious Conditions
    ___Heart Attack
    ___Recent Surgery
    ___Arthritis
    ___Varicose Veins
    ___Use of tobacco
    ___Use of Drugs
    ___Diabetes
    ___Spine Issues
    ___Neck Issues
    ___Back Issues
    ___Other
    This massage is for therapeutic purposes only. I understand the massage services are designed to be health aid and are in
    no way to take the place of a doctors care when it is indicated. Information exchanged during any massage session is
    educational in nature and is intended to help you become more familiar and conscious of your status and is be used at you
    own discretion.
    Name (Signature)_____________________________________________________________________________
    Emergency Contact__________________________________Phone#___________________________________

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