Client Intake & Health History (Massage Therapy)

Client Name: [Legal name] (Required; use "Unknown" or "Declines to provide" if not available)

Preferred Name: [Preferred name, if different from legal name]

Date of Birth: [MM/DD/YYYY] (Required; use "Unknown" or "Declines to provide" if not available)

Date Completed: [MM/DD/YYYY]

Therapist: [Therapist name, credentials, license number]

Date Reviewed: [MM/DD/YYYY]

Demographics & Contact

Address: [Street, City, State, ZIP] (If declined, document "Client declined to provide address")

Phone: [Primary phone] ([mobile / home / work]) | [Secondary phone, if provided] ([mobile / home / work])

Email: [Email address / None]

Preferred Contact Method: [phone / text / email / no electronic contact]

Permissions: Voicemail: [permitted / not permitted] | Text: [permitted / not permitted] | Email: [permitted / not permitted]

Contact Preferences Notes: [Best times, privacy needs, alternate contact instructions]

Emergency Contact

Name: [Full name] (If declined, record "Client declined to provide emergency contact")

Relationship: [Relationship]

Phone: [Phone number]

Permission to Contact in Emergency: [Yes / No]

Care Coordination

(May be marked "Not applicable" for wellness-only visits)

Primary Care Provider: [Name / No PCP] | [Clinic] | [Phone]

Other Treating Providers: [Provider name, role (PT / chiropractor / specialist), clinic, phone, permission to contact: Yes / No] (List each provider; record "None" if no other providers)

Reason for Visit & Goals

Client's Stated Reason for Visit: [Client narrative in their own words]

Visit Type: [problem-focused / wellness-relaxation]

Primary Area(s) of Concern: [Body region(s)] | Body Diagram Reference: [Diagram ID, if used]

Problem-Focused Symptom Details

(If wellness/relaxation visit, record "Wellness/relaxation visit - symptom detail not applicable")

• Onset: [Approximate start date or duration]
• Quality: [tight / dull / sharp / burning / aching / other]
• Severity: [0–10]
• Pattern: [constant / intermittent / variable]
• Provoking Factors: [List]
• Relieving Factors: [List]
• Radiation / Associated Symptoms: [numbness / tingling / weakness / none]
• Functional Impact: [Impact on sleep, work, exercise, daily activities]

Client Goals

Immediate (today's session): [1–3 prioritized goals]

Short-term (coming weeks): [1–3 goals]

What success looks like to client: [Client-defined success criteria]

Health History

(Use "client reports" language throughout; do not document as diagnosis. Expand any "Yes" response with details.)

• Cardiovascular conditions: [Yes / No / Unknown] — (If Yes) Client reports: [hypertension / heart disease / edema / other], type, approximate date/duration, current status [controlled / uncontrolled / monitoring], restrictions or precautions
• Neurologic conditions: [Yes / No / Unknown] — (If Yes) Client reports: [neuropathy / seizures / stroke history / other], type, approximate date/duration, current status [stable / recent changes], restrictions or precautions
• Diabetes: [Yes / No / Unknown] — (If Yes) Client reports: [Type 1 / Type 2 / gestational], duration, current status [controlled / variable], precautions [hypoglycemia risk, neuropathy areas, injection sites]
• Respiratory conditions: [Yes / No / Unknown] — (If Yes) Client reports: [asthma / COPD / other], triggers/controls, precautions [positioning, fragrance sensitivity, rescue inhaler availability]
• Cancer history/current treatment: [Yes / No / Unknown] — (If Yes) Client reports: type/site, approximate diagnosis date, treatment history [surgery / chemo / radiation / immunotherapy], current status [active / surveillance / remission], precautions [lymph involvement, ports, low platelet counts, fatigue]
• Bleeding or clotting disorders: [Yes / No / Unknown] — (If Yes) Client reports: condition and status, anticoagulant use [Yes / No], precautions [pressure limits, avoid deep techniques]
• Skin conditions: [Yes / No / Unknown] — (If Yes) Client reports: [contagious conditions / open lesions / dermatitis / eczema / psoriasis / other], affected locations, precautions [avoid areas, glove use, product sensitivity]
• Autoimmune/inflammatory conditions: [Yes / No / Unknown] — (If Yes) Client reports: condition, flare status [active / quiescent], precautions [pressure tolerance, fatigue, joint sensitivity]
• Pregnancy or postpartum status: [Yes / No / Not applicable] — (If Yes) Gestational age or postpartum timeframe, pregnancy-related precautions or positioning needs
• Implants/medical devices: [Yes / No / Unknown] — (If Yes) Client reports: [ports / pumps / joint replacements / pacemaker / spinal hardware / other], location(s), precautions [no direct pressure, avoid magnets/cupping]
• Recent surgeries/procedures: [Yes / No / Unknown] — (If Yes) Client reports: procedure, date, clearance received [Yes / No / Unknown], restrictions [weight bearing, ROM limits, incision precautions]

Injury History Relevant to Visit

Prior injuries to target areas: [Yes / No / Unknown] — [Details with dates/duration if Yes]

Fracture history: [Yes / No / Unknown] — [Location and approximate dates if Yes]

Current PT/rehab restrictions: [Yes / No / Unknown] — [ROM, weight bearing, or technique limitations if Yes]

Client-reported imaging/specialist findings: [Summary in client's words]

Massage Therapy History

Prior massage experience: [Yes / No] — [Frequency and types if Yes]

Helpful techniques per client: [List]

Unhelpful or undesired techniques: [List]

Pressure tolerance: [light / moderate / firm / variable / unknown]

History of post-massage soreness: [Yes / No / Unknown] — [Typical duration/severity if Yes]

Adverse reactions reported: [fainting / bruising / symptom flares / none] — [Context if applicable]

Medications, Supplements & Allergies

Current medications (prescription and OTC): [List each with optional dose/frequency and safety-relevant indication]

Supplements/vitamins: [List / None]

Medication delivery sites to avoid: Injection sites: [locations / none] | Medication patches: [locations / none] | Medicated topical creams: [locations / none]

Allergies and sensitivities: (Require explicit status; do not leave blank)

• Medication allergies: [List / No known medication allergies / Unknown]
• Latex sensitivity: [Yes / No / Unknown]
• Allergies to oils/lotions/scents: [List / None / Unknown]
• Skin reactivity (easy bruising, fragile skin): [Yes / No / Unknown]

Same-Day Safety Screening

(All items must be addressed before proceeding; provide details for any "Yes" response)

• Fever or symptoms of contagious illness: [Yes / No] — [Details if Yes]
• New or worsening swelling, redness, or warmth in limbs: [Yes / No] — [Details if Yes]
• Chest pain, sudden shortness of breath, or fainting episodes: [Yes / No] — [Details if Yes]
• Open wounds or rashes in treatment areas: [Yes / No] — [Details if Yes]
• Recent surgery or procedure without clearance: [Yes / No] — [Details if Yes]
• Pregnancy relevant to techniques/positioning: [Yes / No / N/A] — [Details if Yes]

Action for flagged items: [session deferred / session modified / proceeded with precautions] — [Specify modifications or precautions]

Client informed of decision: [Yes / No] | Referral or clearance requested: [Yes / No] — [Specify to whom]

Red Flags Requiring Referral

(Screen for: suspected blood clot symptoms, unexplained severe pain, progressive neurologic symptoms, signs of systemic infection, medical instability)

Red flag present: [Yes / No]

(If Yes) Action: Session deferred | Urgency: [emergent / urgent / routine] | Advice given: [Recommended ED / urgent care / PCP / other] — [Client education provided]

Consent & Preferences

Informed Consent Discussion

• [ ] Nature of massage treatment discussed
• [ ] Expected benefits discussed
• [ ] Potential risks (e.g., soreness, bruising) discussed
• [ ] Alternatives including no treatment discussed
• [ ] Right to ask questions and stop/modify treatment at any time affirmed

Brief session plan discussed: [Summary]

Scope Statement: Massage therapy is not a substitute for medical diagnosis or treatment. Client agrees to share changes in health status before each session. Client may withdraw consent at any time.

Draping & Boundaries

Draping preference: [standard / extra coverage / fully clothed]

Areas client does not want touched: [List explicit avoid areas]

Areas requiring explicit discussion before work: [abdomen / gluteal region / inner thigh / chest-pectoral / none] — [Boundaries and communication plan]

Sensitive-area work: [opt-in / opt-out / not offered] (If opt-in, document how contact will occur, draping method, and client's understanding)

Session Preferences

Pressure preference: [light / moderate / firm / adjust as needed]

Positioning limitations: [prone intolerance / pregnancy positioning / ROM limits / none]

Additional modalities consent: [heat / cold / cupping / tools / aromatherapy / none] — [Indicate consent for each offered]

Communication preferences: [talking / quiet / real-time feedback preferred]

Consent by Guardian

(Include only if client is a minor or unable to legally consent)

Guardian name and relationship: [Name, relationship]

Consent method: [in-person signature / written consent on file / verbal with witness]

Guardian presence requirement: [required for full session / required for intake only / not required / per policy]

Therapist Summary

(Brief synthesis in 3–6 bullet points; confirm client goals; use neutral language without medical diagnoses)

• [Primary concern summary]
• [Relevant history highlights (client reports)]
• [Key cautions/precautions identified]
• [Client goals confirmed]
• [Coordination/clearance considerations, if any]

Initial Plan

Focus areas: [Body regions]

General approach: [relaxation-focused / problem-focused / blended]

Planned modifications: [Pressure limits, areas to avoid, positioning accommodations, modality adjustments based on identified risks/preferences]

Follow-up plan: [Frequency, reassessment cadence, referral considerations]

Clinical reasoning: [Brief rationale, non-diagnostic] (Optional)

Signatures

Client Attestation: "The information provided is accurate to the best of my knowledge."

Client Signature: [Signature] | [Printed name] | [Date] | [Time]

Therapist Signature: [Signature] | [Printed name] | [Date] | [Time] | Decision: [proceeded / modified / deferred]