“D” HEART
CLIENT INTAKE FORM - THERAPEUTIC MASSAGE
Personal Information:
Name: ___________________________________ Contact Number: ______________________
Address: ______________________________________________________________________
City/State/Zip: _________________________________________________________________
Email: ___________________________________ Date of Birth: ________________________
Occupation: ______________________________ Emergency Contact: ___________________
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 specify if you have any allergies to the content of oils, lotions, and ointment
________________________________________________________________________
4. Do you have sensitive skin? Yes
No
5. Are you wearing contact lenses ( ) dentures ( ) a hearing aid ( )?
6. Do you sit for long hour at a workstation, computer, or driving? Yes
No
If yes, please describe _____________________________________________________
7. Do you perform any repetitive moment 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 ______________________________________________________
Medical Information
1. Are you taking any medication? Yes
No
If yes, please list name and use: _____________________________________________
2. Are you currently pregnant? Yes
No
If yes, how far along? _____________________________________________________
Any high risk factors? _____________________________________________________
3. Do you suffer from chronic pain? Yes
No
If yes, please explain ______________________________________________________
What makes it better? _____________________________________________________
What makes it worse? _____________________________________________________
4. Have you had any orthopedic injuries? Yes
No
If yes, please list _________________________________________________________
5. Please indicate any of the following that apply to you
Cancer
Fibromyalgia
Headaches / Migraines
Stroke
Arthritis
Heart Attack
Diabetes
Kidney Dysfuntions
Joint Replacement (s)
Blood Clots
High / Low Blood Pressure
Numbness
Neuropathy
Sprains or Strains
Explain any conditions you have marked above:
Massage Information
1. Have you had a professional massage before? Yes
No
2. What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue
Other: __________________________________________________________________
3. What pressure do you prefer?
Light
Medium
Deep