Massage Therapy Client Intake Form

Here's a comprehensive Massage Therapy Client Intake Form, designed to gather essential information and ensure client suitability for various massage services.

Date

Client Information

First Name

Last Name


Date of Birth

Street Address

City/Suburb

State/Province


Postal/Zip Code


Phone Number

Email Address

Emergency Contact

First Name

Last Name


Phone Number

Health History

Primary Care Physician:

Physician's Phone:

Are you currently under the care of a physician?

Please list any current medications (prescription, over-the-counter, supplements):

Please check any of the following conditions you currently have or have had in the past:

Are you currently experiencing any pain or discomfort?

Are you currently experiencing any stress or anxiety?

Do you have any known sensitivities to oils, lotions, or scents?

Massage Preferences & Goals

What are your goals for this massage? (Check all that apply)

Please indicate your preferred massage pressure:

Are there any areas you would like the therapist to focus on?

Are there any areas you would like the therapist to avoid?

Service Selection & Suitability Questions

Please select the massage service you are interested in:

Massage Service

Yes/No

If yes, please explain

Swedish Massage: (Relaxation, stress reduction, light to medium pressure)

 
 

Are you looking for general relaxation and stress relief?

 
 

Are you comfortable with light to medium pressure?

 
 

Deep Tissue Massage: (Muscle tension relief, chronic pain, firm to deep pressure)

 
 

Are you experiencing chronic muscle tension or pain?

 
 

Are you comfortable with firm to deep pressure?

 
 

Do you have any recent injuries or surgeries that might contraindicate deep tissue work?

 
 

Sports Massage: (Injury prevention, recovery, flexibility, varied pressure)

 
 

Are you an athlete or regularly engage in physical activity?

 
 

Are you seeking to improve performance or recover from exercise?

 
 

Do you have any acute injuries that need to be addressed?

 
 

Prenatal Massage: (Relaxation, pain relief during pregnancy, light to medium pressure, specific positioning)

 
 

Are you currently pregnant?

 
 

Have you received clearance from your physician for prenatal massage?

 
 

Do you have any high-risk pregnancy conditions?

 
 

Hot Stone Massage: (Relaxation, muscle tension relief, heat therapy)

 
 

Are you sensitive to heat?

 
 

Do you have any conditions that might be aggravated by heat (e.g., varicose veins, diabetes, skin conditions)?

 
 

Aromatherapy Massage: (Relaxation, mood enhancement, essential oils)

 
 

Do you have any known allergies or sensitivities to essential oils?

 
 

Are you comfortable with the use of essential oils during your massage?

 
 

Reflexology: (Targeted pressure on feet, hands, and ears, stress reduction)

 
 

Do you have any foot, hand or ear injuries or conditions?

 
 

Client Consent

I understand that the massage therapist will be performing a massage for the purpose of relaxation and/or therapeutic benefit.

I have accurately provided my health history and will inform the therapist of any changes in my condition.

I understand that massage therapy is not a substitute for medical treatment, and I am responsible for consulting with my physician for any medical concerns.

I consent to the massage therapy as described and understand that I may stop the massage at any time.

Client Signature

Form Template Insight

Please remove this form template insight section before publishing.


1. Client Information (Demographics):


Purpose:

  • Establishes a client profile for record-keeping and communication.
  • Provides contact information for appointment reminders and follow-ups.
  • Emergency contact details are crucial for safety.

Insight:

  • Accurate data entry is essential.
  • Consider how you will store and protect this sensitive information (e.g., electronic health records, locked filing cabinets).
  • The "How did you hear about us?" question helps with marketing analysis.

2. Health History (Medical Information):


Purpose:

  • Identifies potential contraindications (conditions that make massage unsafe or inappropriate).
  • Helps the therapist understand the client's overall health and tailor the massage accordingly.
  • Protects both the client and the therapist from potential harm.

Insight:

  • This is the most critical section.
  • The therapist must be knowledgeable about various medical conditions and their implications for massage.
  • "Other" fields are vital to capture unique client situations.
  • The pain rating scales are very helpful to track progress.
  • The medication list is important, as some medications can have effects that interact with massage.
  • Pregnancy is a very important question, and it is vital that the therapist is trained in prenatal massage if they offer this service.

3. Massage Preferences & Goals (Client Expectations):


Purpose:

  • Determines the client's desired outcome from the massage.
  • Allows the therapist to customize the session to meet the client's needs.
  • Sets realistic expectations.

Insight:

  • Open-ended questions encourage the client to express their needs.
  • Pressure preference is subjective; the therapist should check in with the client during the massage.
  • Knowing the clients goals, lets the therapist know what techniques to use.

4. Service Selection & Suitability Questions (Informed Consent):


Purpose:

  • Ensures the client understands the different massage services offered.
  • Verifies the client's suitability for the chosen service.
  • Provides informed consent.

Insight:

  • This section promotes transparency and client education.
  • The suitability questions are designed to identify potential risks associated with specific services.
  • For example, deep tissue massage might be contraindicated for clients with certain medical conditions or recent injuries.
  • It is vital that the therapist is trained in the modalities that they offer.
  • The inclusion of specific questions relating to each service, shows that the therapist is taking the clients health seriously.

5. Client Consent (Legal Protection):


Purpose:

  • Documents the client's agreement to receive massage therapy.
  • Protects the therapist from liability.
  • Reinforces the importance of client communication and informed decision-making.

Insight:

  • The consent should be clear and concise.
  • It should emphasize that the client has provided accurate information and understands the risks and benefits of massage.
  • It is a legal document, and should be treated as such.

6. Notes (Therapist Documentation):


Purpose:

  • Provides a space for the therapist to record observations, treatment plans, and progress notes.
  • Facilitates continuity of care.
  • Serves as a legal record of the session.

Insight:

  • Detailed notes are crucial for effective treatment and legal protection.
  • Include information about the client's response to the massage, any areas of concern, and recommendations for future sessions.

Overall Insights:

  • Client-Centered Approach: The form emphasizes gathering information to provide a personalized massage experience.
  • Risk Management: The health history and suitability questions are designed to minimize risks and ensure client safety.
  • Professionalism: A well-designed intake form demonstrates professionalism and attention to detail.
  • Legal Compliance: The consent form and accurate record-keeping are essential for legal protection.
  • Communication: The form encourages open communication between the client and the therapist.

By carefully reviewing and analyzing the information gathered on the client intake form, massage therapists can provide safe, effective, and client-centered care.


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