I know when I first started my Massage Therapy business, oh so many years ago, I was always a little unsure about what to ask the client before they got on the table. Which goes to show that my training on ethics could have been better. But I did my own research and kept at it and here is a pretty normal intake form for all of you noobies to use. Feel free to use it as is or change/tweek some of the questions!

Client Information

Name_________________________________________________________________________

Address_______________________________________City___________________State___________

Phone______________________Email__________________________________

Birth Date____________________Referred By_____________________________________

Here you would want to add any other contact information you want. Maybe ask if they want to be on your mailing list. Honestly, I never asked and just always put them on my mailing and email lists for future promotions.

Okay, then you have your contraindication questions:

All yes or no questions with an area for explanation if needed.

Have you had a professional massage before?

Do you have any skin problems or allergies?

Are you pregnant or nursing?

Do you have varicose veins or blood clots?

Do you have any heart problems?

Do you have arthritis or joint disorders?

Do you have any spinal problems?

Do you have headaches?

Do you have problems sleeping?

Is your lifestyle stressful?

Have you had any significant change in you life recently?

Do you smoke?

Do you exercise or participate on any sports? If so what kind?

_________________________________________________________________________________

Do you take any medications?

_________________________________________________________________________________

Do you have any medical condition that I should be aware of before giving you massage therapy?

Then have them sign for liability purposes.

I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. Likewise, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor does she perform any spinal adjustments.

Signature______________________________________Date____________________________

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