Massage therapy client questionnaire

Massage Therapy Client Questionnaire

Address: ____________________________________________________________________

City: __________________________ State: ______ Zip Code: ______________

Home Phone: __________________________ Work Phone: _______________________

Occupation: ___________________________ Referred by: ________________________

Have you had a professional massage prior to this visit? YES ____ NO ____

Reason for therapeutic massage (major complaint): ___________________________________

What, if any, treatment have you had for this condition? ______________________________

Is there anything that makes your condition worse? Y N ________________________

Please note if you are currently being treated by any of the following practitioners:

Ο Medical Doctor (MD) or Name: ___________________________ Release: Y N

Nurse Practitioner (NP)

Ο Chiropractor Name: ___________________________ Release: Y N

Ο Psychiatrist Name: ___________________________ Release: Y N

Have you had any surgery? Y N (If yes, please explain.) _____________________________

______________________________________________________________________________

Emergency Contact Name & Relation to You: _________________ Phone: ________________

Desired Massage Pressure: Deep/Stress Release ___; Moderate___; Light/Nurturing ___

Sleeping Position: Stomach __, Back __, R side __, L side __ & # of Pillows: 1 _, 2_, 3_

Please select all of the following conditions that currently apply to YOUR health:

Ο Arthritis Ο Stiff Neck Ο Bursitis Ο Allergies Ο High Blood Pressure

Ο Cancer Ο Asthma Ο Chronic Fatigue Ο Sciatica Ο Phlebitis Ο Diabetes

Ο Edema Ο Sinusitis Ο Poor Circulation Ο Pregnancy Ο Hematoma Ο Dizziness

Ο Skin Rash Ο Stroke Ο Varicose Veins Ο HIV/AIDS Ο Headaches Ο Constipation

Ο Back Pain Ο Neck Pain Ο Emphysema Ο Cramps Ο Leg Pain Ο Abuse Survivor

What you can expect in a professional massage:

 A safe and professional environment and approach; to be treated with respect

 To have privacy while undressing & dressing; to be draped except for the area receiving work

 To be accepted without judgment; to be able to stop the therapy at any time

 To be listened to carefully ; to talk or not to talk

 To have control over how much pressure is used

S.S. # ________________________

M.R. #: ______________________

Name: ___________________________________________

Date: _________ D.O.B: __________ Gender: _______

I understand that my massage will be given by a licensed therapist. If I have any specific medical conditions or

symptoms, I have cleared receiving a massage with my primary care provider.

Client Signature: _______________________________________ Date: _________________

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Massage therapy client questionnaire
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