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Client Intake Form Therapeutic Massage

Multi-line address
Birthday
Month
Day
Year

Health Information

Are you taking any medications?
Yes
No
Any allergies? (oils, lotions, nuts, fruits, skin, etc.)
Yes
No
Are you pregnant?
Yes
No
Are you you currently under medical supervision or receiving other medical interventions?
Yes
No
Please choose all that apply:
Areas of broken skin? (e.g. rash, wounds)
Yes
No
History of joint replacement surgery?
Yes
No
Recent injuries or medical procedures (past 2 years)?
Yes
No

Massage Information

Have you had professional massage before?
Yes
No
Reason for seeking massage:
Relaxation
Specific problem
How much pressure do you prefer?
Light
Medium
Firm

By signing below, I acknowledge that I am aware of the benefits and risks

of massage therapy and that I have completed this form to the best of my

knowledge. I also agree to inform my massage therapist of any health or

medical changes.

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Date
Month
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