Central Texas College/Central Campus
Continuing Education Department
Licensed Massage Therapy Program
MSSG 2086 Internship
INTAKE ADDENDUM for FOLLOW-UP SESSIONS
Massage Therapy is regulated as a healthcare profession. Massage therapists are required to do an
initial consultation with each client prior to the first massage therapy session; and a follow-up intake
addendum for each session thereafter. The following questions satisfy the legal requirement for a
consultation document. (Please print legibly)
NAME______________________________________________________DATE_____________________________
Date of your last massage________________
REASON FOR THIS SESSION / TYPE OF MASSAGE (Please check all that apply)
Relaxation
Stress Management
Prenatal
AREAS OF DISCOMFORT OR TENSION
(Please describe or circle areas of
discomfort):
__________________________________
AREAS YOU WISH TO BE AVOIDED
__________________________________
__________________________________
PRESSURE PREFERENCE
Light
Moderate
Deep
Don’t know
WHAT IS YOUR GOAL TODAY?
__________________________________
__________________________________
Please check the appropriate responses for the following questions or put N/A next to question:
1. Have you had any changes in your condition/medications since your last massage?
Yes
No
If yes, please describe_____________________________________________________
2. What is your stress/discomfort level at this time?
1
2
3
4
5
6
Very little
7
8
9
10
Overwhelming
(TURN OVER TO COMPLETE)
Central Texas College/Central Campus
Continuing Education Department
Licensed Massage Therapy Program
MSSG 2086 Internship
Contributing stressors: ___________________________________________________________
Please check quality of discomfort:
Intermittent
Dull
Burning
Sharp
Numbness
Aching
Throbbing
Constant
Stabbing
3. How much does your level of stress/discomfort interfere with your daily activities?
1
2
3
Very little
4
5
6
7
8
9
10
worst possible
Client Signature___________________________________________ Date _______________________________
Internship Student’s Signature ________________________________________Date ______________________
FOR THERAPIST USE ONLY:
S: __________________________________________________________________________________________
_____________________________________________________________________________________________
O: __________________________________________________________________________________________
_____________________________________________________________________________________________
A: __________________________________________________________________________________________
_____________________________________________________________________________________________
P: __________________________________________________________________________________________
_____________________________________________________________________________________________
I: __________________________________________________________________________________________
_____________________________________________________________________________________________
E: __________________________________________________________________________________________
_____________________________________________________________________________________________