Massage Intake Form
1. Personal Information.
_______________________________
_______________________________
Full Name
Date of Birth
_______________________________
_______________________________
Phone Number
Email Address
_____________________________________________________________________
Street Address
_____________________________________________________________________
City/State/ZIP Code
___________________
___________________
___________________
Emergency Contact
Relationship
Phone
How did you hear about us? ______________________________________________
_____________________________________________________________________
2. Medical Information.
Are you taking any medications?
If yes, please list name and use:
Are you currently pregnant?
☐ Yes
☐ No
_______________________________
☐ Yes
☐ No
If yes, how far along?
_______________________________
Any high-risk factors?
_______________________________
Do you suffer from chronic pain?
☐ Yes
☐ No
If yes, please explain:
_______________________________
What makes it better?
_______________________________
What makes it worse?
_______________________________
Have you had any orthopedic injuries?
If yes, please list:
☐ Yes
☐ No
_______________________________
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Please indicate any of the following that apply to you:
☐ Cancer
☐ Arthritis
☐ Fibromyalgia
☐ Heart Attack
☐ Headaches/Migraines
☐ Diabetes
☐ Stroke
☐ Kidney Dysfunction
☐ Joint Replacement(s)
☐ Numbness
☐ Blood Clots
☐ Neuropathy
☐ High/Low Blood Pressure
☐Sprains or Strains
Explain any conditions you have marked above: ______________________________
_____________________________________________________________________
_____________________________________________________________________
3. Massage Information.
Is this your first professional massage?
☐ Yes
☐ No
What type of massage are you seeking?
☐ Relaxation
☐ Deep Tissue
What pressure do you prefer?
☐ Light
Do you have any allergies/sensitivities?
If yes, please explain:
☐ Yes
☐ Medium
☐ Deep
☐ No
_______________________________
Are there any areas (feet, face, abdomen, etc.) you do not want to be massaged?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
What are your goals for this treatment session?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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Please circle any areas of discomfort:
4. Signature.
By signing the form below, the client certifies that they have completed this form to
the best of their ability and knowledge and agree to inform the massage therapist if
any of the above information changes at any time.
_______________________________
_______________________________
Client Signature
Massage Therapist Signature
_______________________________
_______________________________
Date of Signing
Date of Signing
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