Client Intake Form Builder

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[Your Practice Name]
CLIENT HEALTH INTAKE FORM
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PERSONAL INFORMATION

Full Name: ___________________________________________
Date of Birth: ____/____/________
Address: _____________________________________________
City: ____________________  State: _____  Zip: ________
Phone: (____) ____-________
Email: _______________________________________________
Preferred Contact Method:  [ ] Phone  [ ] Text  [ ] Email
Occupation: __________________________________________
Referring Provider (if any): __________________________

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HEALTH HISTORY

Please check any conditions that apply to you, past or present:

[ ] Diabetes                    [ ] Heart Disease
[ ] High Blood Pressure         [ ] Low Blood Pressure
[ ] Arthritis / Joint Problems  [ ] Cancer (current or history)
[ ] Fibromyalgia                [ ] Osteoporosis
[ ] Skin Conditions (eczema, psoriasis, rashes)
[ ] Blood Clots / DVT           [ ] Varicose Veins
[ ] Seizures / Epilepsy         [ ] Migraines / Headaches
[ ] Numbness / Tingling         [ ] Sciatica
[ ] Herniated / Bulging Disc    [ ] Scoliosis
[ ] TMJ Disorder                [ ] Carpal Tunnel Syndrome
[ ] Autoimmune Disorder         [ ] Depression / Anxiety
[ ] Allergies (latex, oils, lotions): _________________
[ ] Recent Surgeries (within 12 months): _____________
[ ] Pregnant — Due Date: ____/____/________
[ ] Other: ___________________________________________

Please list any additional health conditions not mentioned above:
______________________________________________________
______________________________________________________

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CURRENT MEDICATIONS

Please list all medications, supplements, and vitamins you are currently taking, including dosage:

1. ___________________________________________________
2. ___________________________________________________
3. ___________________________________________________
4. ___________________________________________________
5. ___________________________________________________

Are you currently under the care of a physician?  [ ] Yes  [ ] No
If yes, physician name: ______________________________
Physician phone: (____) ____-________

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AREAS OF PAIN OR TENSION

Please check all areas where you experience pain, tension, or discomfort:

[ ] Head / Scalp          [ ] Neck
[ ] Shoulders             [ ] Upper Back
[ ] Mid Back              [ ] Lower Back
[ ] Hips / Glutes         [ ] Upper Legs (thighs)
[ ] Lower Legs (calves)   [ ] Feet / Ankles
[ ] Upper Arms            [ ] Forearms / Hands
[ ] Chest                 [ ] Abdomen
[ ] Jaw / TMJ

Rate your current pain level (circle one):
  0   1   2   3   4   5   6   7   8   9   10
 None                                    Severe

How long have you experienced this pain/tension?
[ ] Less than 1 week   [ ] 1-4 weeks   [ ] 1-6 months
[ ] 6-12 months        [ ] More than 1 year

What makes it worse? __________________________________
What makes it better? _________________________________

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PRESSURE PREFERENCES

Please indicate your preferred massage pressure:

[ ] Light — Gentle, relaxation-focused touch
[ ] Medium — Moderate pressure for general tension relief
[ ] Firm — Strong pressure for deeper muscle work
[ ] Deep — Maximum therapeutic pressure for chronic tension

Are there any areas where you prefer lighter pressure?
______________________________________________________

Are there any areas where you prefer deeper pressure?
______________________________________________________

Do you have any sensitivity to:
[ ] Scented oils / lotions   [ ] Heat (hot stones, warm towels)
[ ] Cold (ice, cool packs)   [ ] Music or sound
[ ] None of the above

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INFORMED CONSENT FOR MASSAGE THERAPY

I understand that massage therapy is provided for the purpose of stress reduction, relief from muscular tension, spasm, or pain, and for improving circulation and energy flow.

I understand that massage therapists do not diagnose illness, disease, or any other physical or mental disorder, and do not prescribe medical treatment or pharmaceuticals, nor perform spinal manipulations.

I acknowledge that massage therapy is not a substitute for medical examination or treatment. I have stated all known medical conditions and will update my therapist of any changes in my health status.

I understand that I may experience some soreness after treatment, which is a normal response to deep tissue work. I will inform my therapist if I experience any pain or discomfort during the session.

I understand that I have the right to refuse or end the session at any time for any reason, and to request modifications to pressure, technique, or areas worked.

I understand that draping will be used during the session to ensure my comfort and privacy, and that only the area being worked on will be uncovered.

Client Signature: _____________________________________
Date: ____/____/________

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EMERGENCY CONTACT

Emergency Contact Name: _______________________________
Relationship: ________________________________________
Phone: (____) ____-________
Alternate Phone: (____) ____-________

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Thank you for completing this form. Your information is kept strictly confidential.
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