Download Massage Intake Form

MASSAGE INTAKE FORM
Date___/___/____
In order to provide you with the best quality massage, please complete this form in its entirety. All information is strictly confidential.
Client Name:___________________________________________________
Massage Information:
Have you ever received professional massage/bodywork before? Yes ☐ No ☐
How recently? ___________________________________
What kind of pressure do you prefer? Light Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
_________________________________________________________________________________________
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How do you feel today? ______________________________________________________________________
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling,
swelling):______________________________________________________________________________________________________________
Do these symptoms interfere with your activities of daily living ( sleep, exercise, work, childcare)? Yes No
Explain:________________________________________________________________________________________________________________
Do you wear contacts? Yes___ No___
Are you Pregnant? Yes___ No___ If so, how many months? ________
Dentures? Yes___ No___
Please explain any tension, pain, stiffness, numbness, tightness or discomfort you may be experiencing, and please
indicate on the bodies to the left with XXX were it is occurring.
____________________________________________________________________________________________________________________________________
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MASSAGE INTAKE FORM
HEALTH HISTORY
Please check any of the following conditions you are experiencing now or have experienced in the
past. Please add comments where you feel necessary.
Musculoskeletal
Spasms/Cramps
Sprains/Strains
Osteoporosis
Gout
Osteoarthritis/Rheumatoid
Arthritis
TMJ (Jaw Pain)
Bursitis
Plantar Fasciitis
Tendonitis
Whiplash Syndrome
Carpal Tunnel
Headache
Scoliosis
Problems walking
Joint Stiffness
Other _________________________
Respiratory
Pneumonia
Sinusitis
Asthma
Trouble Breathing
Dizziness
Other _________________________
Circulatory
Fainting
Cold feet or hands
Stroke
Pressure Sores
Other _________________________
Digestive
Ulcers
Irritable Bowel Syndrome
Colitis
Hepatitis
Gallstones
Crohn’s Disease
Diarrhea
Gas/Bloating
Indigestion
Diverticulitis
Other _________________________
Skin
Fungal Infections
Acne
Impetigo
Dermatitis/Eczema
Psoriasis
Open Wounds or Sore
Rashes
Warts/Moles
Athletes Foot
Cosmetic Surgery
Other _________________________
Nervous System
Multiple Sclerosis
Parkinson’ Disease
Cerebral Palsy
Spinal Cord Injury
Seizure Disorders
Numbness/Tingling/Twitching
Fatigue
Chronic Pain
Other _________________________
Other
Allergies
Insomnia
Anxiety/Panic Attacks
PTSD
Cancer
Depression
Forgetfulness – Confusion
Substance Abuse
Chronic Fatigue
HIV/AIDs
Lupus
Kidney disease
Bladder Infection
Infectious Disease
Fibromyalgia
Any Other congenital or
acquired disabilities____________
___________________________________
___________________________________
Surgeries _____________________
___________________________________
Other
___________________________________
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Anemia
Hemophilia
Hypertension
Low Blood pressure
High Blood Pressure
Varicose Veins
Heart Condition
Blood Clots/Phlebitis
Diabetes
Edema
Please list any additional comments regarding your health and well-being: ____________________________
__________________________________________________________________________________________________________________
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