Massage Therapy Intake Form

Massage Therapy Intake Form — Form Fields

This healthcare template includes 8 fields across 2 pages. Collect client information, health history, and preferences for massage therapy sessions. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Phone Number (text, required)
• Email Address (email, optional)
• Areas of Tension or Pain (checkboxes, optional) — options: Neck, Shoulders, Upper back, Lower back, Legs / Feet, Arms / Hands — Select all that apply.
• Preferred Pressure (dropdown selection, required) — options: Light, Medium, Deep / Firm, No preference
• Are you pregnant? (multiple choice, required) — options: Yes, No, Not applicable
• Health Conditions or Injuries (long text, optional) — e.g., recent surgery, skin conditions, blood pressure issues
• Client Signature (signature, required) — I confirm the above information is accurate and consent to treatment.