Massage Client Intake Form

Collect necessary health and preference information from clients prior to a massage session.

Full Name *

Date of Birth *

Contact Information (Phone or Email) *

Emergency Contact (Name and Phone Number)

Have you had a professional massage before? *

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 PressureHeart ConditionsDiabetesArthritisRecent InjuriesChronic PainSkin ConditionsAllergiesPregnancyOther (please specify)

If you selected 'Other', please specify

Are you currently taking any medications? *

If yes, please list your medications

Do you have any allergies (e.g., lotions, oils, essential oils)?

Preferred pressure level for the massage *

Additional comments or concerns

Signature of Client *

Date of Submission *

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