Massage Intake Form Please complete this form before your massage appointment. For privacy, personal information fields are built to avoid browser AutoFill suggestions and the form clears after the PDF is generated. Client Information First Name Last Name Email Phone Date of Birth Age Address Emergency Contact Name Emergency Contact Phone Relationship Select relationship Spouse Family Member Friend Other Occupation Referred By Health Information Are you taking any medications? Yes No If yes, list medications Any allergies? Oils, lotions, nuts, fruits, skin, etc. Yes No If yes, list allergies Are you pregnant? Yes No Months / due date Under medical supervision or medical intervention? Yes No If yes, please describe Check Yes or No for each condition Areas of broken skin? Rash, wounds, etc. Yes No Where? History of joint replacement surgery? Yes No Which joints? Recent injuries or medical procedures in past 2 years? Yes No If yes, please describe Please describe any other injuries or health conditions Massage Information Have you had professional massage before? Yes No How recently? Reason for seeking massage Relaxation Specific problem Other If other, please describe Pressure Preference Light Medium Firm Body Map - Check massage areas of concern Front Back Scalp / Head Jaw / TMJ Neck Shoulders Chest / Pecs Abdomen Forearms / Hands Hips / Front Thighs Knees / Shins Ankles / Feet Neck Upper Back Mid Back Low Back Hips / Glutes Hamstrings Calves Ankles / Feet Check the body areas that are painful, tight, sensitive, or where you want focused massage work. Areas to avoid or areas of discomfort Areas where you would like extra focus Session goals / notes for therapist Consent By submitting this form, I acknowledge that massage therapy is not a substitute for medical care, diagnosis, or treatment. I have completed this form to the best of my knowledge and agree to inform my massage therapist of any health or medical changes. I understand that I may stop or modify the session at any time. Client Signature Clear Signature Sign above with your finger, stylus, or mouse. Date Generate PDF After generating the PDF, a download button will appear so the completed form can be saved to the device. PDF Created Your completed massage intake PDF is ready. Download PDF Tap Download PDF to save the completed form to this device.