Massage Intake Form Template – Canada

The Massage Intake Form Template – Canada is provided in several formats, including PDF, Word, and Google Docs. These formats are customizable and ready for printing, ensuring a smooth experience tailored to your requirements.

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Sample

Massage Intake Form Template – Canada

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1. Client Information



2. Emergency Contact Information

3. Health History

4. Current Medications

5. Allergies

6. Reason for Treatment

7. Treatment Preferences

8. Previous Massage Experience

9. Consent Acknowledgment

10. Client Signature and Date


11. Therapist Use Only

PDF

WORD

Examples

Massage Intake Form Template – Canada (1)
Patient Information:
Name: [Patient’s Name]
Date of Birth: [Patient’s Date of Birth]
Address: [Patient’s Address]
Phone Number: [Patient’s Phone]
Email: [Patient’s Email]
Emergency Contact:
Name: [Emergency Contact’s Name]
Relationship: [Relationship to Patient]
Phone Number: [Emergency Contact’s Phone]
Health History:
Do you have any allergies? [Yes/No] If yes, please specify: [Allergies Details]
Do you have any current health issues? [Yes/No] If yes, please specify: [Health Issues Details]
Medications:
Are you currently taking any medications? [Yes/No] If yes, please list: [Medications List]
Massage Purpose:
What is your primary reason for seeking massage therapy? [Massage Purpose Details]
Preferred Techniques:
Do you have any preferred massage techniques? [Preferred Techniques Details]
Consent:
I consent to receive massage therapy and understand the risks involved. [Signature Line]
Date: [Date]
Massage Intake Form Template – Canada (2)
Patient Information:
Name: [Patient’s Name]
Date of Birth: [Patient’s Date of Birth]
Address: [Patient’s Address]
Phone Number: [Patient’s Phone]
Email: [Patient’s Email]
Emergency Contact:
Name: [Emergency Contact’s Name]
Relationship: [Relationship to Patient]
Phone Number: [Emergency Contact’s Phone]
Health Assessment:
Please describe any injuries or surgeries: [Injuries/Surgeries Details]
Do you have any chronic conditions? [Yes/No] If yes, please specify: [Conditions Details]
Current Pain Levels:
On a scale of 1 to 10, please rate your current pain level: [Pain Level]
Massage Goals:
What do you hope to achieve through massage therapy? [Massage Goals Details]
Additional Notes:
Please provide any additional information that may be relevant: [Additional Notes]
Consent:
I understand that massage therapy is a complementary health approach and consent to receive treatment. [Signature Line]
Date: [Date]

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Massage Intake Form Template - Canada