Simple Touch Therapeutic Massage

Client Intake Form

Name

Date of Birth

Phone (Cell)

Phone (Other)

Address

City/State/Zip

Email

Occupation

Emergency Contact (Name & Phone)

How did you hear about us?

The following information will be used to help plan a safe and effective massage session. Please answer the questions to the best of your knowledge.

1. Have you had a professional massage before?      Yes      No

How recently?

2. If yes, what type of pressure do you typically prefer?

Light          Medium         Deep

3. Do you sit or stand for long periods of time?

Yes      No

    If yes, please explain

4. Do you perform any repetitive motion in your work, sports, or hobby?

Yes      No

    If yes, please explain

5. How would you rate your typical stress level?

Low        Medium        High

6. Is there a particular area of the body where you are currently experiencing pain, tension, stiffness, or discomfort?

Yes      No

    If yes, please explain

7. Do you have any particular goals in mind for this massage session?

Yes      No

    If yes, please explain

8. Are there any areas you prefer NOT to have worked on?

Yes      No

    If yes, please identify

Medical History

In order to plan a massage session that is safe and effective, we need some general information about your medical history.

9. Are you currently being treated for an illness or injury?        

Yes      No

    If yes, please explain

10. Are you currently taking any pain medication or blood thinners?

Yes      No

    If yes, please explain

11. Please check any condition listed below that applies to you (past or present):

broken bones/fractures

contagious skin condition

recent surgeries

easy bruising        

accidents/injuries

varicose veins

sprains/strains

deep vein thrombosis/blood clots

tendinitis/carpal tunnel/tennis elbow

high or low blood pressure

artificial joints

cancer

joint disorder/arthritis

diabetes

osteoporosis

fibromyalgia

headaches/migraines

TMJ

epilepsy

pregnancy             If yes, how many weeks?

Please explain any condition that you have marked above

12. Is there anything else about your health history that you think would be useful for your massage therapist to know?

Draping will be used during the session – only the area being worked on will be uncovered.

Informed written consent must be provided by parent or legal guardian for any client under the age of 18.

I, ___________________________________________,(print your name) understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

Signature _________________________________________________           Date _________________________