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Client Pre-Massage Assessment Form

Gathers a client's pain history, injuries, and areas of discomfort ahead of a therapeutic massage session.

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Full Name*

First Name

Last Name

Birth Date

Phone Number*

E-mail*

Address*

Street Address

City

State / Province

ZIP / Postal Code

This is my:*

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number*

Notes on the body diagram

1. List Areas of Discomfort or Pain*

2. Describe Onset of Discomfort or Pain*

3. Rate of Pain Today*

4. Frequency - please select the most accurate*

Constant Intermittent Occasional Rare

5. At what time of day is the pain at its worse?*

Morning Afternoon Evening Night

6. Have you ever injured this area before?*

7. Have you ever been in an accident (automobile, work, falls, etc.) ?*

8. List all related treatments received for this injury.

9. Have you ever received therapeutic massage for a specific problem or injury?

Was the treatment used effective?

10. Is there anything that you do that creates, increases or decreases pain?*

11. What are the physical duties required of your occupation?*

12. What activities/hobbies do you enjoy?*

13. Please list exercise and stress reduction activities (including frequency).*

14. In what position do you most often wake up?*

On Your Back On Your Side On Your Stomach Varies

15. Are you currently seeing any other healthcare professional?

Please mark all areas that apply:

Head

Neck

Shoulders

Arms & Hands

Mid-Back

Low Back

Hip

Legs and Feet

Date

Signature*

Sign here

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