Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Massage Therapy Intake Form
Massage Client Intake Form Please complete this form to help us understand your health history and preferences for a safe and effective massage experience.
Full Name *
Date of Birth *
____ / ____ / ________
Contact Information (Phone or Email) *
Emergency Contact (Name and Phone Number)
Have you had a professional massage before? *
- Yes
- No
What is the primary reason for today's massage? (e.g., relaxation, pain relief, injury recovery) *
Are there any specific areas of the body you'd like us to focus on?
Please indicate any areas of the body you would like us to avoid
Do you have any of the following health conditions? (Check all that apply)
- High Blood Pressure
- Heart Conditions
- Diabetes
- Arthritis
- Recent Injuries
- Chronic Pain
- Skin Conditions
- Allergies
- Pregnancy
- Other (please specify)
If you selected 'Other', please specify
Are you currently taking any medications? *
- Yes
- No
If yes, please list your medications
Do you have any allergies (e.g., lotions, oils, essential oils)?
Preferred pressure level for the massage *
- Light
- Medium
- Firm
Additional comments or concerns
Consent I confirm that the information provided is accurate to the best of my knowledge. I understand that massage therapy is not a substitute for medical examination, diagnosis, or treatment and that I should see a physician for any health issues of concern. I give my consent to receive massage therapy.
Date of Submission *
____ / ____ / ________
Massage Therapy Intake Form template from formisoft.com. formisoft.com/intake-templates/massage-therapy-intake