COVID-SAFE Mobile Massage ~ Serving Greater San Diego
COVID-SAFE Mobile Massage ~ Serving Greater San Diego
MASSAGE CLIENT INTAKE FORM
Please complete this intake form before the day of your massage.
Massage therapy by Louise Hughes is a therapeutic treatment. I need to understand your lifestyle, physiology, medical issues, needs and goals to provide the proper treatment.

"Karl Jung, one of the pioneers of modern psychology, believed that if you want to see how something is going to unfold, look at how it starts. If this idea were applied to massage, then the focus would be on the intake process, which is the start of a bodywork session. It is the foundation on which the massage sits. The right massage can only come from the right information.

Once a therapist has the client's health information, the next step is knowing what to do with it.
A plan will be crafted based on what the client is experiencing."

- Excerpt from Medicine Hands: Massage Therapy for People with Cancer by Gayle MacDonald
Personal Information
Name
Date
Address
City
State
Zip
Phone
Email
Date of Birth



History
Exercise Frequency
Exercise Type(s)
How much water do you drink per day?
What medications are you currently using?
Previous complaints/surgeries/medications
What is your major complaint?
Have you received massage therapy before?
Goals for massage therapy today?
Preferred type of touch


Do You Have Any of the Following Today?
Check All That Apply
If you selected OTHER, please explain


Select Areas of Discomfort
Check All That Apply
If you selected OTHER, please explain


Acknowledgement and Release of Liability
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