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Template: Medical Intake
Massage Client Intake Form
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Collect necessary health and preference information from clients prior to a massage session.
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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
Signature of Client
*
Sign Here
Date of Submission
*
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