"Massage Intake Form"

What Is a Massage Intake Form?

A Massage Intake Form is a document that contains information about a client who would like to receive massage therapy. The purpose of the document is to provide an establishment that provides massages with the written consent of the client to receive a massage, as well as proof that the client is aware of the risks a massage might present.

Alternate Names:

  • Massage Therapy Intake Form;
  • Client Intake Form.

The document also provides the establishment with the client's medical history. It is necessary to receive a signed filled in form before the massage intake, since a massage can influence the client's condition if they have any serious health issues or chronic diseases.

A massage intake form is supposed to be kept by an establishment for at least one year, as well as other client records. Nonetheless, it can be a good idea to check with the state law that regulates the subject for further information. A Massage Intake Form template can be downloaded below.

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How to Make A Massage Intake Form?

It can seem to be easy to make intake forms for receiving a massage, however, they require a lot of information that needs to be designated. Missing important points can cause serious problems for the establishment, that is why they should make a thorough development regarding the development of their intake form. The document can contain parts, which include the following:

  • Information About the Establishment. In the first part of the form, the establishment should provide their name, location, and contact information. It can be convenient for the client to see the establishment's information when they will be filling in the form;
  • Client's Personal Information. Clients can use this part to designate their full name, gender, and date of birth. This information is needed for identification purposes.
  • Client's Contact Information. Here clients can state their email, telephone number, and current address. The address should include their zip code, state, city, street name, and building number. This information is needed in case the establishment will need to contact the client;
  • Emergency Contact Information. In this part of the document, the client can enter the name of the person who should be contacted in the case of any emergency, their telephone number, and their address. If anything happens to the client this person will be contacted first;
  • Client's Medical History. This is the biggest part of the form and should describe the medical condition of the client. It should be presented as a list of conditions and illnesses, where the client is supposed to mark the ones that they have or have had in the past. Some of the important illnesses and conditions that should be included in the form are heart attack, stroke, seizure, cancer, diabetes, etc. This part should also include questions whether the client is taking any medication, if they have had any surgeries or accidents, whether they are pregnant, and other questions that can describe the client's condition;
  • Client's Consent. The client is supposed to give consent to the establishment to keep their medical records and will be disclosed if it is required by law. In addition to this, the client should designate that they are aware of the massage's risks and that there is no guarantee of its success;
  • Client's Signature. To state that everything written in the form is true and correct the client should sign the document, date it, and hand it to an authorized representative of the establishment.

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Massage Intake Form
1. Personal Information.
_______________________________
_______________________________
Full Name
Date of Birth
_______________________________
_______________________________
Phone Number
Email Address
_____________________________________________________________________
Street Address
_____________________________________________________________________
City/State/ZIP Code
___________________
___________________
___________________
Emergency Contact
Relationship
Phone
How did you hear about us? ______________________________________________
_____________________________________________________________________
2. Medical Information.
Are you taking any medications?
☐ Yes
☐ No
If yes, please list name and use:
_______________________________
Are you currently pregnant?
☐ Yes
☐ No
If yes, how far along?
_______________________________
Any high-risk factors?
_______________________________
Do you suffer from chronic pain?
☐ Yes
☐ No
If yes, please explain:
_______________________________
What makes it better?
_______________________________
What makes it worse?
_______________________________
Have you had any orthopedic injuries?
☐ Yes
☐ No
If yes, please list:
_______________________________
©​ ​ ​ ​
T EMPLATEROLLER.COM​
Massage Intake Form
1. Personal Information.
_______________________________
_______________________________
Full Name
Date of Birth
_______________________________
_______________________________
Phone Number
Email Address
_____________________________________________________________________
Street Address
_____________________________________________________________________
City/State/ZIP Code
___________________
___________________
___________________
Emergency Contact
Relationship
Phone
How did you hear about us? ______________________________________________
_____________________________________________________________________
2. Medical Information.
Are you taking any medications?
☐ Yes
☐ No
If yes, please list name and use:
_______________________________
Are you currently pregnant?
☐ Yes
☐ No
If yes, how far along?
_______________________________
Any high-risk factors?
_______________________________
Do you suffer from chronic pain?
☐ Yes
☐ No
If yes, please explain:
_______________________________
What makes it better?
_______________________________
What makes it worse?
_______________________________
Have you had any orthopedic injuries?
☐ Yes
☐ No
If yes, please list:
_______________________________
©​ ​ ​ ​
T EMPLATEROLLER.COM​
Please indicate any of the following that apply to you:
☐ Cancer
☐ Arthritis
☐ Fibromyalgia
☐ Heart Attack
☐ Headaches/Migraines
☐ Diabetes
☐ Stroke
☐ Kidney Dysfunction
☐ Joint Replacement(s)
☐ Numbness
☐ Blood Clots
☐ Neuropathy
☐ High/Low Blood Pressure
☐Sprains or Strains
Explain any conditions you have marked above: ______________________________
_____________________________________________________________________
_____________________________________________________________________
3. Massage Information.
Is this your first professional massage?
☐ Yes
☐ No
What type of massage are you seeking?
☐ Relaxation
☐ Deep Tissue
What pressure do you prefer?
☐ Light
☐ Medium
☐ Deep
Do you have any allergies/sensitivities?
☐ Yes
☐ No
If yes, please explain:
_______________________________
Are there any areas (feet, face, abdomen, etc.) you do not want to be massaged?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
What are your goals for this treatment session?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
©​ ​ ​ ​
T EMPLATEROLLER.COM​
Please circle any areas of discomfort:
4. Signature.
By signing the form below, the client certifies that they have completed this form to
the best of their ability and knowledge and agree to inform the massage therapist if
any of the above information changes at any time.
_______________________________
_______________________________
Client Signature
Massage Therapist Signature
_______________________________
_______________________________
Date of Signing
Date of Signing
©​ ​ ​ ​
T EMPLATEROLLER.COM​
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