Author: Ben.Johnston

Ability Physical Therapy - Therapeutic Massage Client Intake Form

Name: _______________________Cell Phone:_______________Home Phone:____________

Address:_____________________________________________________________________
City/State/Zip:____________________________________ Date of Birth: ____/_____/______
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 sessions.
Please answer the questions to the best of your knowledge.

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Have you ever had a professional massage before? Yes No
If yes, how often do you receive massage therapy? ______________________________
Do you have any difficulty lying on your front, back, side? Yes No
If yes, please explain _____________________________________________________
Do you have any allergies to oils, lotions, or ointments? Yes No
If yes, please explain _____________________________________________________
Do you have sensitive skin? Yes No
Are you wearing: ( ) Contact lenses ( ) Dentures ( ) Hearing Aid?
Do you sit for long hours at a workstation, computer, or driving? Yes No
If yes, please briefly describe _______________________________________________
Do you perform any repetitive movement in your work, sports, or hobbies? Yes No
If yes, please briefly describe ______________________________________________
Do you currently have any: ( ) muscle tension ( ) anxiety ( ) insomnia ( ) irritability
( ) other: ______________________________________________________________
Is there a particular area of the body that you are experiencing tension, stiffness, pain?
If yes, please identify _____________________________________________________
Do you have any particular goals in mind for this session? Yes No
If yes, please explain: _____________________________________________________
Circle any specific areas you
would like the massage therapist
to concentrate on during the session.
Please continue to the back side for your
Medical History.

Medical History

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

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Are you currently under medical supervision? Yes No
If yes, please explain ______________________________________________________
Do you see a chiropractor? Yes No Who?____________ How often:_____________
Are you currently taking any medication? Yes No If yes, please list below.
__________________________________________________________________________________________________________________________________________________________________________________
Please check any condition listed below that applies to you:
( ) Contagious skin condition ( ) Phlebitis ( ) Tennis Elbow
( ) Open sores or wounds ( ) Blood clots ( ) TMJ
( ) Easy bruising ( ) Joint disorder ( ) Arthritis
( ) Osteoarthritis / Osteoporosis ( ) Tendonitis ( ) Depression
( ) Epilepsy ( ) Swollen Glands ( ) Varicose Veins
( ) Diabetes Level: 1 2 ( ) Headache / Migraines ( ) Allergies
( ) Blood pressure: Low High ( ) Fibromyalgia ( ) Artificial Joint(s)
( ) Fever within 24 hours ( ) Decreased Sensation ( ) Heart Condition
( ) Sprains / Strains ( ) Circulatory Disorder ( ) Carpel Tunnel Syndrome
( ) Pregnancy: Trimester: 1 / 2 / 3 ( ) Gestational Diabetes ( ) Other:________________
( ) Cancer:_______________________________________________________________________________
( ) Recent Injury/Fracture/Surgery If yes, Explain: ______________________________________________
Please include any other condition not listed above. _______________________________________________ _________________________________________________________________________________________
Draping will be used at all times during the session - only the area being worked on will be uncovered.
Clients under the age of 18 must have informed written consent signed by a parent or guardian prior to the start of the session.
I, ________________________ (print 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 techniques may be adjusted to my level of comfort. I further understand that a massage can not be used 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 used as such. 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 shall I fail to do so.

Patient Signature:__________________________________________ Date:______________
Parent or Legal Guardian ( if under 18): ___________________________________________