The Massage Intake Form Template – Australia is offered in multiple formats, including PDF, Word, and Google Docs. These formats are both modifiable and print-ready, providing you with flexibility to suit your requirements.
Massage Intake Form Template – Australia Editable | PrintableSample
1. Client Information 2. Emergency Contact Information 3. Health History 4. Current Medications 5. Reason for Massage 6. Preferred Massage Techniques 7. Past Massage Experiences 8. Consent and Acknowledgment 9. Signature and Date
PDF
WORD
Examples
[Client’s Full Name]
[Client’s Date of Birth]
[Client’s Address]
[Client’s Phone Number]
[Client’s Email Address]
[Emergency Contact Name]
[Emergency Contact Number]
[Relationship to Client]
Please list any medical conditions, injuries, surgeries, or relevant health information:
[Details]
Please list any medications you are currently taking:
[Details]
What are your primary reasons for seeking massage therapy?
[Details]
Do you have any specific preferences for pressure, areas to focus on, or areas to avoid?
[Details]
I consent to receive massage therapy and have disclosed all medical history relevant to treatment. I understand that it is my responsibility to inform the therapist of any changes in my health status.
[Client’s Signature]
[Date]
[Client’s Full Name]
[Client’s Date of Birth]
[Client’s Address]
[Client’s Phone Number]
[Client’s Email Address]
How did you hear about us?
[Details]
Do you have any chronic conditions? Please detail any past injuries, surgeries, or other medical concerns:
[Details]
Do you have any allergies, especially to oils or lotions?
[Details]
Have you had a massage before? If yes, how was your experience?
[Details]
Please list any specific areas where you experience pain or discomfort:
[Details]
What type of massage are you interested in? (e.g., Swedish, deep tissue, sports)
[Details]
I confirm that the information provided is accurate to the best of my knowledge and consent to the treatment.
[Client’s Signature]
[Date]
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