Client Intake Form for Massage Therapy

Client Information

First Name

Last Name


Date of Birth

Gender

Street Address

City/Suburb

State/Province


Postal/Zip Code


Phone Number

Email Address


Emergency Contact Name

Emergency Contact Number


Preferred Communication Method

Health History

Medical Conditions

Do you have or have you been diagnosed with any of the following? (Check all that apply)

Recent Injuries or Surgeries

Have you had any recent injuries, surgeries, or accidents?

Medications

Are you currently taking any medications?

Allergies or Sensitivities

Do you have any allergies or sensitivities (e.g., to oils, lotions, scents)?


Pregnancy

Are you currently pregnant or possibly pregnant?

Skin Conditions

Do you have any skin conditions (e.g., eczema, psoriasis, rashes)?

Other Health Concerns

Is there anything else we should know about your health?

Massage Preferences

Type of Massage

(Check all that interest you)

Pressure Preference

Areas of Focus

Which areas of your body would you like the therapist to focus on?

Areas to Avoid

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

Temperature Preferences

Do you prefer a warm or cool environment?

Music and Ambiance

Do you have any preferences for music or ambiance?

Lifestyle and Goals

Activity Level

How would you describe your activity level?

Stress Level

How would you rate your current stress level?

Massage Goals

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

Frequency of Massage

How often do you receive massage therapy?

Consent and Agreement

Informed Consent

I understand that massage therapy is not a substitute for medical treatment or diagnosis. I have disclosed all relevant health information and will inform my therapist of any changes.

Signature

Cancellation Policy

I understand that I must provide at least 24 hours' notice to cancel or reschedule an appointment, or I may be charged a fee.

Signature

Privacy Policy

I understand that my personal information will be kept confidential and will not be shared without my consent.

Signature

Form Template Insight

Please remove this form template insight section before publishing.


The Massage Therapy Client Intake Form is a critical tool for both the client and the massage therapist. It serves several important purposes, ensuring that the massage session is safe, effective, and tailored to the client's needs. Below is an in-depth insight into the key components of the form and their significance:


1. Client Information

  • Purpose: Collects basic contact details and emergency information.
  • Insight: This section ensures the therapist can communicate with the client and reach out to an emergency contact if needed. It also helps in maintaining accurate records for future sessions.

2. Health History

  • Purpose: Identifies any medical conditions, injuries, allergies, or sensitivities that may affect the massage.

Insight:

  • Medical Conditions: Helps the therapist avoid techniques or pressure that could exacerbate conditions like high blood pressure, osteoporosis, or diabetes.
  • Recent Injuries/Surgeries: Ensures the therapist avoids areas that are healing or may require special care.
  • Medications: Some medications (e.g., blood thinners) can increase sensitivity or bruising risk, so the therapist can adjust pressure accordingly.
  • Allergies/Sensitivities: Prevents the use of oils, lotions, or scents that could cause an allergic reaction.
  • Pregnancy: Prenatal massage requires specialized techniques, and this information ensures the therapist can provide a safe session.
  • Skin Conditions: Helps the therapist avoid irritated or sensitive areas.

This section is crucial for ensuring the client's safety and comfort during the session.


3. Massage Preferences

Purpose: Allows the client to communicate their preferences and goals for the session.


Insight:

  • Type of Massage: Different techniques (e.g., Swedish, deep tissue, hot stone) serve different purposes, and this helps the therapist tailor the session.
  • Pressure Preference: Ensures the therapist applies the right amount of pressure to meet the client's comfort level.
  • Areas of Focus/Avoidance: Directs the therapist to focus on problem areas (e.g., tight shoulders) or avoid sensitive areas (e.g., recent injury sites).
  • Temperature and Ambiance: Enhances the client's comfort and relaxation during the session.

This section ensures the massage is personalized and meets the client's expectations.


4. Lifestyle and Goals

Purpose: Provides context about the client's daily life and what they hope to achieve from the massage.


Insight:

  • Activity Level: Helps the therapist understand the client's physical demands (e.g., sedentary desk job vs. active athlete).
  • Stress Level: Indicates whether the client needs a relaxing session or one focused on stress relief.
  • Massage Goals: Clarifies whether the client seeks relaxation, pain relief, improved flexibility, or other outcomes.
  • Frequency of Massage: Helps the therapist gauge the client's experience level and plan accordingly.

This section helps the therapist design a session that aligns with the client's lifestyle and goals.


5. Consent and Agreement

Purpose: Establishes clear communication about policies and client responsibilities.


Insight:

  • Informed Consent: Ensures the client understands the scope of massage therapy and its limitations.
  • Cancellation Policy: Sets expectations for rescheduling or canceling appointments.
  • Privacy Policy: Reassures the client that their personal information will be kept confidential.

This section protects both the client and the therapist by setting clear boundaries and expectations.


6. Therapist Notes

Purpose: Allows the therapist to document observations and plan for the session.


Insight:

  • Client’s Primary Concerns: Helps the therapist address the client's main issues during the session.
  • Observations: Notes on posture, gait, or muscle tension can guide the therapist's approach.
  • Plan for Session: Outlines the techniques and focus areas for the massage.

This section ensures the therapist has a clear plan to provide an effective and targeted session.


Why This Form is Important

  • Safety: Identifies contraindications or conditions that may require modifications to the massage.
  • Personalization: Tailors the session to the client's preferences, goals, and physical needs.
  • Communication: Opens a dialogue between the client and therapist, ensuring clarity and trust.
  • Legal Protection: Provides documentation of the client's health history and consent, protecting both parties.
  • Efficiency: Saves time by gathering all necessary information upfront, allowing the therapist to focus on the session.

How to Use the Form Effectively

  • For Clients: Be honest and thorough when filling out the form. The more information you provide, the better the therapist can meet your needs.
  • For Therapists: Review the form carefully before the session and ask follow-up questions if anything is unclear. Use the information to create a safe, effective, and personalized treatment plan.

This intake form is a foundational tool for building a positive and professional client-therapist relationship, ensuring a successful massage therapy experience.



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