Massage Intake Form PDF Details

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.

QuestionAnswer
Form NameMassage Intake Form
Form Length2 pages
Fillable?Yes
Fillable fields70
Avg. time to fill out14 min 30 sec
Other namessample massage therapy intake form, medical massage verification form template, massage form printable, massage intake form template

Form Preview Example

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.

Name

 

 

 

 

 

Date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

State

 

City

Home Phone

 

 

 

 

 

 

 

 

 

 

 

Work Phone

 

 

Occupation

 

 

Have you ever received massage therapy?

 

Yes

 

No

Type of massage experienced (swedish, shiatsu, deep tissue, etc.)

Are you currently taking any medications?

 

Yes

 

No

If yes, please list name and reason for medications

Are you currently seeing a healthcare professional?

 

Yes

 

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 auto-immune condition* hepatitis (A, B, C, other) skin conditions stroke

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

 

cold/flu

 

open cuts

 

severe pain

anything contagious

 

injuries/bruises

 

 

Do you have any allergies to:

medications

 

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:

 

contact lenses

 

hearing aid

 

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

How to Edit Massage Intake Form Online for Free

This PDF editor was developed to be as straightforward as possible. Since you use the next actions, the process of filling out the massage form template file will undoubtedly be trouble-free.

Step 1: The first thing is to press the orange "Get Form Now" button.

Step 2: At this point, you're on the form editing page. You can add text, edit current details, highlight certain words or phrases, place crosses or checks, insert images, sign the template, erase unnecessary fields, etc.

Fill out all of the following parts to create the form:

part 1 to filling in sample massage therapy intake form

Provide the expected particulars in the space please, do, so

Finishing sample massage therapy intake form stage 2

You should identify the necessary details in the Do, you, have, any, of, the, following, today skin, rash cold, flu open, cuts, severe, pain anything, contagious injuries, bruises Do, you, have, any, allergies, to medications, foods, nuts, etc reactions, to, skin, care, products Are, you, wearing and contact, lenses, hearing, aid, hairpiece part.

Filling in sample massage therapy intake form stage 3

You will need to define the rights and obligations of both parties in field .

Finishing sample massage therapy intake form step 4

Step 3: Click the Done button to be certain that your completed file may be exported to every electronic device you select or sent to an email you indicate.

Step 4: Make copies of your file - it may help you avoid possible complications. And don't be concerned - we cannot disclose or view your information.

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