Client Pre-Massage Assessment Form

Full Name

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

This is my:

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Format: (000) 000-0000.

History of Pathology

1. List Areas of Discomfort or Pain

2. Describe Onset of Discomfort or Pain

3. Rate of Pain Today

4. Frequency - please select the most accurate

5. At what time of day is the pain at its worse?

6. Have you ever injured this area before?

7. Have you ever been in an accident (automobile, work, falls, etc.) ?

8. List all related treatments received for this injury.

9. Have you ever received therapeutic massage for a specific problem or injury?

Was the treatment used effective?

10. Is there anything that you do that creates, increases or decreases pain?

11. What are the physical duties required of your occupation?

12. What activities/hobbies do you enjoy?

13. Please list exercise and stress reduction activities (including frequency).

14. In what position do you most often wake up?

Other

15. Are you currently seeing any other healthcare professional?

Please check any symptoms that apply to you and indicate right or left when applicable:

Head

Neck

Shoulders

Arms & Hands

Mid-Back

Low Back

Hip

Legs and Feet

Date

Signature

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