Massage Therapy Client Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Emergency Contact Name
Emergency Contact Phone
Health Information
Are you currently under a physician's care?
Yes
No
If yes, for what reason?
List any medications you are currently taking
Allergies (including skin sensitivity)
Medical Conditions / Surgeries
Are you pregnant?
Yes
No
Reason for Visit
What is the primary reason for your visit?
Areas of tension, pain, or discomfort
Preferred Pressure
Light
Medium
Firm
Contraindications
Check any conditions that apply:
Fever
Recent Injury
Infection
Inflammation
Blood Clots
Other (please specify):
Massage History
Have you received professional massage before?
Yes
No
Preferences, likes/dislikes
Additional Information
What are your goals for today's session?
Notes