Clay Co. Massage Therapy — Client Intake Form

Client Information

Full Name

Date of Birth

Phone

Occupation

Email

Emergency Contact

Emergency Contact Phone

Massage Information

Have you ever previously received professional massage therapy?

Yes No

Type(s) of massage(s) experienced

Do you have any orthopedic injuries?

Yes No

Please describe

Do you have chronic pain?

Yes No

Please describe

Do you exercise regularly?

Yes No

Do you have any of the following?

What type of massage do you prefer/require?

Relaxation Therapeutic / Deep Tissue Other

Please specify

What pressure do you prefer/require?

Light Medium Firm

Goals for this treatment session

Areas of Focus

Please select all areas where you would like focus, are feeling tense, or are experiencing discomfort:

Medical History

Please check all that apply:

Other

Are you currently taking any medications?

Yes No

Please explain

Do you have any allergies/sensitivities to fragrances, oils, lotions, fruits, or nuts?

Yes No

Please explain

Do you smoke or consume alcohol?

Smoke Alcohol Both None

How much/how often?

Health Concerns / Massage Consent

Do you have any of the following today? Check all that apply:

Would you like to be added to my email list for specials and discounts?

Yes No

How did you hear about me?

Client Signature

Sign here with your finger or mouse

Date

Clay Co.

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