Therapy Intake Form PDF Details

The Therapy Intake Form serves as an essential gateway for crafting personalized and safe therapeutic massage sessions, representing a critical first step in addressing an individual's specific needs and health concerns. Gathering personal information, including contact details and emergency contacts, sets the foundation. Further inquiries meticulously catalog prior massage experiences, any existing difficulties with lying in specific positions, allergies, and personal habits such as prolonged periods of sitting or repetitive movements. It also delves into the realms of stress, pinpointing its sources and impacts, while also identifying targeted areas of discomfort and objectives for the session. Complementing this personal narrative is a detailed medical history, crucial for planning a course of treatment that acknowledges and accommodates any health conditions, ensuring both safety and efficacy. This comprehensive approach not only tailors the massage to the individual but also mandates informed consent, encapsulating a holistic view of the client's well-being, reinforcing the practice's dedication to safety, and fostering a transparent and trust-fueled relationship between client and therapist. Such meticulous intake ensures that every therapeutic massage session is not just a routine treatment but a step towards individualized care and relief.

QuestionAnswer
Form NameTherapy Intake Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesclient therapeutic massage, client intake massage, form massage template, form therapeutic pdf

Form Preview Example

Client Intake Form – Therapeutic Massage

Personal Information:

Name

 

 

 

 

 

Phone (Day)

 

 

 

Phone (Eve)

 

Address

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

email

 

 

 

Date of Birth

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

Emergency Contact

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Date of Initial Visit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Have you had a professional massage before?

Yes

No

 

 

 

 

 

 

If yes, how often do you receive massage therapy?

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Do you have any difficulty lying on your front, back, or side?

Yes

No

 

 

 

If yes, please explain

 

 

 

 

 

 

 

 

 

 

 

3.

Do you have any allergies to oils, lotions, or ointments?

Yes

No

 

 

 

 

 

If yes, please explain

 

 

 

 

 

 

 

 

 

 

 

4.

Do you have sensitive skin?

Yes

No

 

 

 

 

 

 

 

 

5.

Are you wearing contact lenses ( ) dentures ( ) a hearing aid (

) ?

 

 

 

 

6.

Do you sit for long hours at a workstation, computer, or driving?

 

Yes

No

 

 

If yes, please describe

 

 

 

 

 

 

 

 

 

 

 

7.

Do you perform any repetitive movement in your work, sports, or hobby?

Yes

No

 

If yes, please describe

 

 

 

 

 

 

 

 

 

 

8.

Do you experience stress in your work, family, or other aspect of your life?

Yes

No

 

If yes, how do you think it has affected your health?

 

 

 

 

 

 

muscle tension ( ) anxiety ( )

insomnia (

) irritability (

) other

 

 

 

 

9.

Is there a particular area of the body where you are experiencing tension, stiffness, pain

 

 

or other discomfort? Yes

No

 

 

 

 

 

 

 

 

 

 

If yes, please identify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Do you have any particular goals in mind for this massage session?

Yes

No

 

 

If yes, please explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Circle any specific areas you would like the massage therapist to concentrate on during the session:

Continued on page 2

Medical History

In order to plan a massage session that is safe and effective,

I need some general information about your medical history.

11. Are you currently under medical supervision? Yes

No

If yes, please explain

 

 

 

 

 

 

 

 

 

 

12. Do you see a chiropractor? Yes

No

If yes, how often?

 

 

13. Are you currently taking any medication?

Yes

No

If yes, please list

 

 

 

 

 

 

 

 

 

 

14. Please check any condition listed below that applies to you:

(

) contagious skin condition

(

) phlebitis

 

 

(

) open sores or wounds

(

) deep vein thrombosis/blood clots

(

) easy bruising

(

) joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis

(

) recent accident or injury

(

) osteoporosis

(

) recent fracture

(

) epilepsy

 

 

(

) recent surgery

(

) headaches/migraines

(

) artificial joint

(

) cancer

 

 

(

) sprains/strains

(

) diabetes

 

 

(

) current fever

(

) decreased sensation

(

) swollen glands

(

) back/neck problems

(

) allergies/sensitivity

(

) Fibromyalgia

(

) heart condition

(

) TMJ

 

 

(

) high or low blood pressure

(

) carpal tunnel syndrome

(

) circulatory disorder

(

) tennis elbow

(

) varicose veins

(

) pregnancy If yes, how many months?

(

) atherosclerosis

 

 

 

 

Please explain any condition that you have marked above

15.Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?

Draping will be used during the session – only the area being worked on will be uncovered.

Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.

I,(print name) understand that the massage I receive is provided

for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

Signature of client

 

Date

 

Signature of Massage Therapist

 

Date

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1. The form massage template needs certain details to be typed in. Be sure that the following fields are complete:

client intake form massage fill conclusion process clarified (stage 1)

2. After the first array of blanks is filled out, go on to type in the suitable information in all these: Do you have any allergies to oils, Yes, If yes please explain, Do you have sensitive skin, Yes, Are you wearing contact lenses, Do you sit for long hours at a, Yes, If yes please describe, Do you perform any repetitive, Yes, If yes please describe, Do you experience stress in your, Yes, and If yes how do you think it has.

How one can prepare client intake form massage fill portion 2

3. This next step is generally easy - complete every one of the blanks in Medical History In order to plan a, Are you currently under medical, If yes please explain, Do you see a chiropractor, Yes, If yes how often, Are you currently taking any, Yes, If yes please list, Please check any condition listed, contagious skin condition, phlebitis, open sores or wounds, deep vein thrombosisblood clots, and easy bruising in order to finish this segment.

Stage # 3 in filling out client intake form massage fill

4. Now complete this next form section! In this case you'll have all of these Please explain any condition that, Is there anything else about your, know to plan a safe and effective, Draping will be used during the, Clients under the age of must be, Informed written consent must be, print name understand that the, for the basic purpose of, session I will immediately inform, comfort I further understand that, diagnosis or treatment and that I, mental or physical ailment that I, spinal or skeletal adjustments, the course of the session given, and certain medical conditions I blanks to fill in.

Filling in section 4 of client intake form massage fill

5. The last stage to finalize this PDF form is crucial. Make certain you fill out the appropriate blanks, for example Signature of client, Signature of Massage Therapist, Date, and Date, before submitting. Neglecting to do it can lead to a flawed and potentially incorrect form!

The best way to complete client intake form massage fill step 5

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