Client Intake Form

Personal Information

Name: Date: Phone Number: Email Address: Date of Birth:

Health Information

Do you have any medical conditions? Yes No If yes, please specify: Are you currently taking any medications? Yes No If yes, please list: Any allergies? Yes No If yes, please specify: Primary reason for today’s visit:

Massage Preferences

Preferred pressure level: Light Medium Firm Areas of focus: Areas to avoid:

Consent

By signing below, I consent to receive massage therapy and confirm that the information provided above is accurate and complete to the best of my knowledge.

Client Signature (Type your name): Date: