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MMW-Form-IntakeForm 221025 215604

This document is a massage intake form collecting personal and medical information from a new client. It requests contact details, medical history including medications, injuries, and conditions. It asks about the client's massage experience and preferences for pressure. The client signs agreeing to provide accurate information and update the therapist of any changes. The therapist also signs agreeing to the client's treatment.

Uploaded by

Xiomara Maysonet
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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148 views1 page

MMW-Form-IntakeForm 221025 215604

This document is a massage intake form collecting personal and medical information from a new client. It requests contact details, medical history including medications, injuries, and conditions. It asks about the client's massage experience and preferences for pressure. The client signs agreeing to provide accurate information and update the therapist of any changes. The therapist also signs agreeing to the client's treatment.

Uploaded by

Xiomara Maysonet
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Massage Intake Form

Personal Information
Name ________________________________________ Phone (day) _____________________ (evening) _____________________

Address _____________________________________ City/State/Zip _________________________________ DOB ___________

Occupation _____________________________________________ Employer ___________________________________________

Email _______________________________________________ Primary Physician _______________________________________

Emergency Contact ____________________________________ Relationship __________________ Phone __________________

How did you hear about us? ____________________________________________________________________________________

Medical Information Massage Information


Are you taking any medications? ☐ yes ☐ no Have you had a professional massage before? ☐ yes ☐ no
If yes, please list name and use: _____________________ What type of massage are you seeking?
_______________________________________________ ☐ Relaxation ☐ Therapeutic/Deep Tissue
Are you currently pregnant? ☐ yes ☐ no Other ___________________________________________
If yes, how far along? ______________________________ What pressure do you prefer?
Any high risk factors? ______________________________ ☐ Light ☐ Medium ☐ Deep
Do you suffer from chronic pain? ☐ yes ☐ no Do you have any allergies or sensitivities? ☐ yes ☐ no
If yes, please explain ______________________________ Please explain ________________________________
What makes it better? _____________________________ Are there any areas (feet, face, abdomen, etc.) you do not
_______________________________________________ want massaged? ☐ yes ☐ no
Please explain _______________________________
What makes it worse? ____________________________
What are your goals for this treatment session?
_______________________________________________
_____________________________________________
Have you had any orthopedic injuries? ☐ yes ☐ no
Please circle any areas of discomfort
If yes, please list: ________________________________
Please indicate any of the following that apply to you.

☐ Cancer ☐ Fibromyalgia
☐ Headaches/Migraines ☐ Stroke
☐ Arthritis ☐ Heart Attack
☐ Diabetes ☐ Kidney Dysfunction
☐ Joint Replacement(s) ☐ Blood Clots
☐ High/Low Blood Pressure ☐ Numbness
☐ Neuropathy ☐Sprains or Strains

By signing below, you agree to the following.


Explain any conditions you have marked above: I have completed this form to the best of my ability and knowledge
and agree to inform my therapist if any of the above information
________________________________________________
changes at any time.
________________________________________________
________________________________________________ Client Signature __________________________ Date __________

________________________________________________ Therapist Signature _______________________ Date __________

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