Client Intake Form

Please complete before your first treatment. It takes about two minutes and stays confidential.

Step 1 of 5

Client information

Full name

Phone

Date of birth

Age

Address

Postcode

Occupation

Referred by

Emergency contact

Name

Phone

Relationship

Massage information

Have you had professional massage before?

Yes No

How recently?

Reason for seeking massage

Relaxation Specific problem Other

Please tell us more

How much pressure do you prefer?

Light Medium Firm

Areas of discomfort

Tap every area where you feel pain, tension or discomfort. Leave blank if you have none.

Head & neck

Head Face / jaw Neck Shoulders

Back

Upper back Mid back Lower back Shoulder blades

Arms & hands

Upper arms Elbows Forearms Wrists / hands

Torso

Chest Abdomen Ribs / sides Hips

Legs & feet

Glutes Thighs Knees Calves Ankles Feet

Anything else about those areas? Left or right side, how long it has been there, what makes it worse.

Health information

Are you taking any medications?

Yes No

Please list them

Any allergies?Oils, lotions, nuts, fruits, skin reactions.

Yes No

Please list them

Are you pregnant?

Yes No

How many months

Due date

History of joint replacement surgery?

Yes No

Which joint(s)?

Any broken bones in the past 6 months?

Yes No

Where were the broken bones?

Recent injuries or medical procedures in the past 2 years?

Yes No

Please describe

Any other injuries or health conditions?

Consent & signature

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.

Sign with your finger

Sign here

✓

Thank you

Your intake form has been sent to Love Thai Massage. Your therapist will go through it with you before your treatment.