Thank you for choosing [Massage Business Name]! To ensure the best possible massage experience, please complete this form.

Client Information

  • Full Name:
  • Date of Birth:
  • Phone Number:
  • Email Address:

Emergency Contact Information

  • Name:
  • Relationship:
  • Phone Number:

Health History

  • Are you currently pregnant or suspect you may be pregnant? (Yes/No)

  • Do you have any allergies? (Yes/No) If yes, please list:

  • Do you have any of the following conditions? (Please check all that apply)

    • High blood pressure
    • Heart disease
    • Diabetes
    • Cancer
    • Blood clots
    • Osteoporosis
    • Arthritis
    • Skin conditions (eczema, psoriasis, etc.)
    • Recent surgery
    • Any other medical conditions (please specify):

  • Are you currently taking any medications? (Yes/No) If yes, please list:

  • Have you ever had a massage before? (Yes/No) If yes, how often?

  • What are your goals for this massage (e.g., relaxation, pain relief, improved circulation)?

Treatment Preferences

  • What areas would you like the massage therapist to focus on?
  • What pressure level do you prefer (light, medium, firm)?
  • Do you have any specific techniques you would like the therapist to use (e.g., Swedish massage, deep tissue massage, trigger point therapy)?
  • Is there anything else you would like the massage therapist to know about your preferences?

Client Signature

By signing below, I acknowledge that I have read and understood the information provided on this form. I agree to inform the massage therapist of any changes in my health condition before my massage session.

  • Signature:
  • Date:

Additional Information

  • You may be asked to complete a separate informed consent form for specific massage techniques.
  • Please arrive 10 minutes early for your first appointment to allow time for check-in.
  • We have a cancellation policy requiring [number] hours notice.
  • We accept [list accepted payment methods] for payment.

Thank you! We look forward to providing you with a relaxing and therapeutic massage experience.

Disclaimer: This template is for informational purposes only and should not be considered a substitute for professional medical advice. It's recommended to consult with a lawyer to ensure your massage intake form meets all legal requirements in your jurisdiction.