MASSAGE THERAPY INTAKE FORM
Today’s Date:
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Name
Signature
Have you had professional massage before?
Yes
No
Do you have an allergies or skin sensitivities to oils or lotions?
Yes
No
Are you currently taking any medications, prescription or over-the-counter?
Yes
No
If yes, please list (i) Name of Medications:
(ii) Reason for Medications:
Please check off any condition below that applies to you:
High Blood Pressure
Low Blood Pressure
Cancer
DVT / Blood Clots
Heart Condition
Easy Bruising
Circulatory Issues
Artificial Joints?
Any metal, wires, pins, plates in body?
Diabetes
Thyroid Condition
Osteoporosis
Arthritis
Epilepsy
Is there anything else about your health history that you think would be useful for your massage therapist to know?
Please indicate the letter that applies to any specific areas you would like the massage therapist to concentrate on during the session:
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
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