Massage Therapy Treatment Plan Form
Complete this form to provide the details needed to plan your massage therapy treatment and appointment preferences.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Session Date and Time
Treatment Planning
Primary reason for visit
*
Please Select
Relaxation
Pain relief
Stress reduction
Muscle tension
Injury recovery support
Improved flexibility
Sports recovery
Prenatal comfort
Other
Treatment goals
*
Preferred pressure level
*
Very light
Light
Medium
Firm
Deep
No preference
Preferred massage areas
Neck
Shoulders
Upper back
Lower back
Arms
Hands
Chest
Abdomen
Glutes
Hips
Legs
Feet
Scalp
Full body
Other
Health Screening and Acknowledgment
Relevant Health Concerns or Conditions
None
Recent injury
Pregnancy or possible pregnancy
Skin condition or rash
Blood clotting issue
High blood pressure
Neuropathy
Chronic pain
Other
Submit
Should be Empty: