Client Intake Form

This form helps me plan your massage session. Your responses send securely and privately — not stored on a server.

Personal Information

This information is used for booking and maintaining your client record. If you prefer to remain anonymous, you may skip these fields.

Your name (First Last)

Your email

Date of Birth (dd-mm-yyyy)

Gender
Male Female Other

Do you have an insurance?
Yes No

Your Lifestyle

This information helps me understand your lifestyle, physical activity level, daily workload, and other factors that may affect your muscles, joints, and overall health.

Please, describe your Work environment:
Sedentary (office / desk job)
Lightly active (cashier, teacher, standing or light walking)
Moderately active (warehouse, delivery, on feet most of the day)
Highly active (athlete / construction)

Exercise or sports activity?
No Occasionally (1–2×/week) Regularly (3+×/week)

Medical Info

Your medical conditions and health history are important for planning a safe and appropriate massage treatment.

Do you have Fatigue / Stress / Emotional strain
None Occasionally (1–2×/week) Often (3–5×/week) Constant (daily)

Do you have any musculoskeletal issues to address:
Neck Shoulders Upper or Mid Back Lumbar Glutes Arms Legs Other

Do you have any traumas in the past:
No Yes

Please list any medical conditions relevant to massage:

Please confirm before submitting!
I do NOT have any of the following conditions: Tuberculosis, Syphilis, HIV/AIDS, Active Hepatitis, or STI

About Your Massage

This information helps me prepare for your visit, plan your massage session, and create the most comfortable environment possible.

Have you had a professional massage before?
Yes No

What type of massage are you looking for?
Therapeutic Relaxation Other
If "Other", you can describe below:

Preferred pressure:
Light Medium Deep

Preferred draping:
Standard / Maximum Minimal No draping

Preferred lighting:
Bright Dim Complete darkness

Aroma:
Use Do not use

Music:
Loud Quiet Barely audible No music

Almost Done

Just a few final details before submitting your form.

Additional information you'd like to share (optional):
Feel free to share what brings you here—whether it's tension seeking release, a mood you'd like to shift, or something your body’s been trying to tell you.

I am not allergic to dogs or plants, or I have allergies but can manage them myself.

Please note: in my massage clinic, you can customize many things to suit your preferences and needs for maximum effect. Pressure, pace, lighting, music, and more are all in your control. Feel free to share your ideas in the field above or discuss them on site.