Massage Therapy Client Intake Form

Capture contact information, an emergency contact, medications and the discomfort history of people coming to your massage therapy practice. It helps you understand habits, sleep posture and affected areas before the first session.

Use this template

In the Claude connectors directory

Full name

First Name

Last Name

Date

Address

Street Address

City

State / Province

ZIP / Postal Code

Date of birth

Phone number

This person is my:

Emergency contact

First Name

Last Name

Emergency contact phone

Occupation

Medications

Allergies

1. List areas of discomfort or pain

2. Describe how the discomfort or pain began

3. Pain level today

4. Frequency (choose the most accurate)

Constant Frequent Occasional Rarely

5. What time of day is the pain worst?

6. Have you injured this area before?

7. Have you ever been in an accident (car, work, fall, etc.)?

8. List any treatments received for this injury

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

Was that treatment effective?

10. Does anything cause, increase or relieve the pain?

11. What physical demands does your job involve?

12. What activities or hobbies do you enjoy?

13. List your exercise and stress-relief activities (with frequency)

14. What position do you usually wake up in?

15. Are you currently seeing another healthcare professional?

Symptoms by body area

I confirm the information provided is accurate

Date

Signature

Sign here

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