First Name
Last Name
Date of Birth
Phone Number
Email Address
Emergency Contact Name
Phone Number
What is the primary focus for today's session? (Check all that apply)
Deep Relaxation & Stress Relief
Muscle Tension & Knot Relief
Pain Management / Injury Recovery
Improved Mobility & Flexibility
Target Specific Areas Only
Pressure Preferences & Sensitivity
General Pressure Preference
Light Touch: Soft, gentle, relaxing pressure.
Medium Pressure: Balanced, firm enough to relieve mild tension without discomfort.
Firm / Deep Tissue: Strong, targeted pressure to work through deep muscle layers.
Variable: Different pressure for different areas (specify below).
Indicate preferred pressure for specific body regions:
Pressure Mapping
Indicate preferred pressure for specific body regions:
Body Region | Light | Medium | Deep | Avoid Completely | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Neck & Shoulders | |||||
2 | Upper & Mid Back | |||||
3 | Lower Back | |||||
4 | Arms & Hands | |||||
5 | Legs & Feet | |||||
6 | Scalp & Face |
Body Region Focus & Avoidance
Please select one option for each body region below to customize your session. Use the notes column to add specific details (e.g., 'right side only' or 'recent strain').
Body Area | Standard Work | Extra Attention | Avoid Entirely | Details / Specific Notes | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Head / Scalp | |||||
2 | Neck / Shoulders | |||||
3 | Upper Back / Scapula | |||||
4 | Lower Back / Glutes | |||||
5 | Arms / Hands | |||||
6 | Legs / Feet / Calves |
Do you currently have or have a history of any of the following?
High or Low Blood Pressure
Varicose Veins or Blood Clots
Recent Surgeries, Fractures, or Sprains (within last 6 months)
Allergies (Oils, Nuts, Latex, Fragrances, Aromatherapy)
Skin Conditions (Eczema, Open Wounds, Contagious Rash)
Pregnant or Possibility of Pregnancy (If yes, how many weeks?
Chronic Pain, Arthritis, or Joint Issues
Please detail any checked items or additional health conditions
Aromatherapy
Yes, please
No scent / Fragrance-free
Music / Sound
Soft Instrumentals
Nature Sounds
Silence
Room Temperature
Extra Warm (Heated Table On)
Moderate
Cool
Conversation
Silent / Quiet Treatment
Open to Light Conversation
I understand that massage therapy is intended for relaxation, stress reduction, and muscle tension relief. It is not a substitute for medical examination, diagnosis, or treatment. I have disclosed all known health conditions and will inform my therapist immediately if I experience discomfort or require a change in pressure during the session.
Client Signature
Form Template Insights
Please remove this form template insights section before publishing.
Having verified client contact details ensures accurate record-keeping, seamless booking management, and clear identification. Gathering emergency contact details establishes a vital safety protocol, giving therapists immediate access to support if a client experiences a sudden health issue, allergic reaction, or medical event during treatment.
Asking clients to state their primary goal—whether deep relaxation, targeted knot release, or improved mobility—aligns therapist technique with client expectations. This prevents misunderstandings, helps set realistic session outcomes, and ensures every minute on the table directly addresses what matters most to the client.
Pressure sensitivity varies dramatically across different areas of the human body. Capturing a client’s preferred depth for specific body zones eliminates uncomfortable guesswork. It reduces session interruptions for constant adjustments, prevents post-massage soreness or bruising, and creates a tailored experience that makes clients feel truly heard.
Identifying priority zones alongside total avoidance areas maximizes treatment efficiency and client safety. Therapists can allocate session time effectively toward problem areas like tight shoulder blades or lower back tension while avoiding sensitive skin, ticklish areas, or healing injuries. This creates a comfortable environment where clients can fully relax without anxiety about painful spots being touched.
Massage therapy directly impacts circulation, muscle tissue, and the nervous system. Screening for conditions like high blood pressure, recent surgeries, blood clots, or allergies to massage oils protects client physical well-being. It allows therapists to modify techniques, select safe topical products, and avoid contraindications that could cause physical harm or aggravate existing conditions.
A successful massage involves more than physical technique; sensory environment plays a massive role in stress reduction. Asking about room temperature, music style, aromatherapy scents, and conversation level lets clients curate their ideal environment. Tailoring these subtle details elevates the treatment from a basic service to a premium spa experience.
This section clearly sets boundaries around professional scope, defining massage therapy as a wellness practice rather than a medical treatment. It establishes a shared understanding between therapist and client, reinforcing the client's responsibility to communicate discomfort and giving the practitioner clear authorization to proceed with the customized treatment plan.
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation before publishing.
Setting specific questions as mandatory (required) in your digital form builder prevents clients from accidentally skipping critical information. Unanswered fields force therapists to pause the session to ask follow-up questions, cutting into hands-on treatment time and risking client physical well-being.
Here are the mandatory questions for this template and the practical reasons to enforce them:
To configure an element, select it on the form.