If you are a massage therapist, you know that the Massage Intake Form is an important part of your business. The form allows you to gather important information about your clients, including their health history and any specific concerns they may have. By having this information on hand, you can provide your clients with the best possible massage experience. In this blog post, we will discuss the importance of the Massage Intake Form and share some tips for completing it correctly.
We have gathered some interesting information regarding the massage intake form. You'll have the projected time you will need to fill out the form and a few other details.
| Question | Answer |
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| Form Name | Massage Intake Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | massage intake forms download, massage form, massage form template, massage forms form |
Massage Intake Form - CONFIDENTIAL INFORMATION
WELCOME! I would like to make your appointment as pleasant and comfortable as possible. If at any time you have questions regarding your session, please let me know.
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Date of birth |
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Address |
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State |
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City |
Home Phone |
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Work Phone |
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Occupation |
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Have you ever received massage therapy? |
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Yes |
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No |
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Type of massage experienced (swedish, shiatsu, deep tissue, etc.)
Are you currently taking any medications? |
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Yes |
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No |
If yes, please list name and reason for medications
Are you currently seeing a healthcare professional? |
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Yes |
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No |
If yes, please list names and reason/treatment
Please review this list and check those conditions that have affected your health either recently or in the past. Place a check mark next to the condition.
arthritis diabetes blood clots broken/dislocated bones bruise easily
cancer chronic pain constipation/diarrhea
surgery TMJ disorder
(*AIDS, fibromyalgia, chronic fatigue, lupus, etc.)
depression, panic disorder, other psych condition
diverticulitis headaches heart conditions back problems high blood pressure insomnia
muscle strain/sprain pregnancy scoliosis seizures whiplash
chemical dependency (alcohol, drugs)
If any of the above needs to be detailed or if there is anything else to share,
please do so:
Do you have any of the following today:
skin rash |
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cold/flu |
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open cuts |
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severe pain |
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anything contagious |
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injuries/bruises |
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Do you have any allergies to:
medications |
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foods (nuts, etc.) |
environmental allergens (dust, pollen, fragrances)
reactions to skin care products
If any of the above are checked, please give details:
Are you wearing: |
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contact lenses |
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hearing aid |
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hairpiece |
Please indicate with an (X), if any, the areas in which you are feeling discomfort:
What are your goals/expectations for this therapy session?
The following sometimes occurs during massage. They are normal responses to
relaxation. Trust your body to express what it needs to:
need to move or change position ! sighing, yawning, change in breathing
stomach gurgling ! emotional feelings and/or expression
movement of intestinal gas ! energy shifts ! falling asleep ! memories
Please read the following information and sign below:
1.I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and treatment.
2.This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.
3.Being that massage should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully.
Signature:Date