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    Client Intake Form - Therapeutic Massage

    Uploaded by

    Peter Sosa
    This document contains a client intake form for a therapeutic massage. It collects information such as contact details, medical history, areas of pain or tension, goals for the session, and provides liability waivers. The form is used to plan a safe and effective massage by identifying any medical conditions, injuries, or sensitive areas to avoid. It also makes clear that massage should not replace medical treatment and the client is responsible for communicating accurately about their health.

    Copyright:

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

    Client Intake Form - Therapeutic Massage

    Uploaded by

    Peter Sosa
    240 views2 pages
    This document contains a client intake form for a therapeutic massage. It collects information such as contact details, medical history, areas of pain or tension, goals for the session, and provides liability waivers. The form is used to plan a safe and effective massage by identifying any medical conditions, injuries, or sensitive areas to avoid. It also makes clear that massage should not replace medical treatment and the client is responsible for communicating accurately about their health.

    Original Description:

    Massage Intake Form

    Original Title

    Intake Form

    Copyright

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    This document contains a client intake form for a therapeutic massage. It collects information such as contact details, medical history, areas of pain or tension, goals for the session, and provides liability waivers. The form is used to plan a safe and effective massage by identifying any medical conditions, injuries, or sensitive areas to avoid. It also makes clear that massage should not replace medical treatment and the client is responsible for communicating accurately about their health.

    Copyright:

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

    Client Intake Form - Therapeutic Massage

    Uploaded by

    Peter Sosa
    This document contains a client intake form for a therapeutic massage. It collects information such as contact details, medical history, areas of pain or tension, goals for the session, and provides liability waivers. The form is used to plan a safe and effective massage by identifying any medical conditions, injuries, or sensitive areas to avoid. It also makes clear that massage should not replace medical treatment and the client is responsible for communicating accurately about their health.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Client Intake Form – Therapeutic Massage

    Name___________________________ Phone (Day) ___________________Cell____________________


    Address______________________________________City/State/Zip______________________________
    Email______________________________________ Occupation _________________________________
    Date of Birth___________ Referred by ______________________________________________________
    Emergency Contact ____________________________________________ Phone___________________

    The following information will be used to help your therapist plan a safe and effective massage
    session. Please answer the questions to the best of your knowledge.

    Have you had a professional massage before? Yes No If yes, how often? ________________________
    Do you have any difficulty lying on your front, back, or side? Yes No
    If yes, please explain ______________________________________________________________
    Do you have any allergies to oils, lotions, ointments, fruits or nuts? Yes No
    If yes, please explain ______________________________________________________________
    Do you have sensitive skin? Yes No
    Are you wearing contact lenses dentures a hearing aid prosthetics?
    Do you sit for long hours at a workstation, computer, or driving? Yes No
    If yes, please describe _____________________________________________________________
    Do you perform any repetitive movement in your work, sports, or hobby? Yes No
    If yes, please describe _____________________________________________________________
    How do you feel the stress in your work, family, or other aspect of your life affected your health?
    muscle tension anxiety insomnia irritability other___________________
    Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?
    Yes No If yes, please identify____________________________________________________
    Do you have any particular goals in mind for this massage session? Yes No
    If yes, please explain______________________________________________________________

    Circle any specific areas you would like the massage therapist to concentrate on during the session:
    Medical History
    Do you currently or have you ever had any of the following: (please check)
    phlebitis tennis elbow
    deep vein thrombosis/blood clots recent fracture
    joint disorder recent surgery
    rheumatoid arthritis/osteoarthritis/tendonitis artificial joint
    osteoporosis sprains/strains
    epilepsy current fever
    headaches/migraines swollen glands
    cancer allergies/sensitivity
    diabetes heart condition
    decreased sensation high or low blood pressure
    back/neck problems circulatory disorder
    Fibromyalgia varicose veins
    TMJ atherosclerosis
    carpal tunnel syndrome easy bruising
    contagious skin condition recent accident or injury
    open sores or wounds pregnancy If yes, how many months?

    Are you currently under medical supervision? Yes No


    If yes, please explain_______________________________________________________________
    Do you see a chiropractor? Yes No If yes, how often?________________________________________
    Are you currently taking any medication? Yes No
    If yes, please list _________________________________________________________________
    Is there anything else about your health history that you think would be useful for your massage therapist to
    know to plan a safe and effective massage session for you? ____________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________

    I understand that the massage I receive is provided for the basic purpose of relaxation and relief of
    muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the
    therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand
    that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and
    that I should see a physician other qualified medical specialist for any mental or physical ailment that I am
    aware of. I understand that massage therapists are not qualified to perform adjustments, diagnose,
    prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given
    should be construed as such. Because massage should not be performed under certain medical conditions,
    I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to
    keep the therapist updated as to any changes in my medical profile and understand that there shall be no
    liability on the therapist’s part should I fail to do so.

    Signature of client ______________________________________________ Date ___________________

    Signature of Massage Therapist ___________________________________ Date ___________________

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