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?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmassage intake forms download, massage form, massage form template, massage forms form

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

Watch Massage Intake Form Video Instruction

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