Intake Form

Personal Information

Full Name: Date of Birth: Address: Phone Number: Email Address: Emergency Contact Name: Emergency Contact Relationship: Emergency Contact Phone Number:

Health History & Current Medical Information

Current Medical Conditions: Past Surgeries or Injuries: Medications & Supplements: Allergies/Sensitivities: Current Symptoms & Pain Areas: Contraindications (if any):

Massage Therapy Goals & Preferences

Type of Massage Requested: --Select-- Deep Tissue / Therapeutic Massage Swedish/Relaxation Massage Sports Massage Other If Other, please specify: Primary Goals for Your Session: Previous Massage Therapy Experience:

Consent, Acknowledgement & Legal Disclosures

Please read the following and acknowledge by typing your full name as a signature.

I understand that massage therapy is a therapeutic modality that can provide relief and improve function, but it is not a substitute for medical care. I agree to notify the therapist of any changes in my health during the session. I confirm that I have provided all relevant medical information.

I voluntarily consent to massage therapy and release [Your Practice Name] and its affiliates from liability related to treatment. I acknowledge potential risks and confirm that I have had the opportunity to ask questions.

Client Signature (Type Your Full Name): Date:

S.O.A.P. Pre-Treatment Survey

Subjective

Describe your primary symptoms or concerns: On a scale of 1–10, rate your current pain or discomfort level: --Select-- 1 2 3 4 5 6 7 8 9 10 Additional comments on how you’re feeling (stress, fatigue, etc.):

Objective

Have you observed any physical signs (e.g., swelling, bruising, limited range of motion)? If so, please describe:

Assessment

How would you describe the nature of your discomfort or condition?

Plan

What are your goals for today’s session and your long-term treatment? Additional notes or requests for your treatment plan:

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