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Massage client intake form
Name
*
Email Address
*
Phone Number
*
Health Information
Any Allergies? (oils, lotions, skin, etc.)
*
Yes
No
Areas of broken skin? (e.g. rash, wounds)
*
Yes
No
If yes, Where?
History of joint replacement surgery?
*
Yes
No
Which joint(s) ?
Recent injuries or medical procedures in the past 2 years?
*
Yes
No
If yes, Please describe:
*
Massage Information
Please indicate any areas of discomfort (Right Side)
*
R 1
R2
R3
R4
R5
R6
R7
R8
R9
R10
R11
R12
R13
R14
Please indicate any areas of discomfort (Left Side)
*
L1
L2
L3
L4
L5
L6
L7
L8
L9
L10
L11
L12
L13
L14
What type of massage would like? (You can choose more than one.)
*
How much pressure do you prefer?
*
A
Light
B
Medium
C
Firm
By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.
Client Signature
*
Signature
Submit
