Scribd
Upload
15 views6 pages

Client Massage Therapy Questionnaire

This document is a client questionnaire for a massage therapy session. It collects information such as contact details, medical history, areas of tension, and preferences for the session. The client reports daily activities including sports and hobbies. They note their reason for visiting is for relaxation and muscle tension. Previous massage experience is discussed.

Uploaded by

Carla Frazer
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
15 views6 pages

Client Massage Therapy Questionnaire

This document is a client questionnaire for a massage therapy session. It collects information such as contact details, medical history, areas of tension, and preferences for the session. The client reports daily activities including sports and hobbies. They note their reason for visiting is for relaxation and muscle tension. Previous massage experience is discussed.

Uploaded by

Carla Frazer
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

client questionnaire

Last Name:____________________________ First Name:__________________________

Today's Date: ___/___/___

Home Address: ____________________________________

____________________________________

Phone (home/or cell): ___________ Phone (work): ___________ Date of Birth: ___/___/___

Height: _______ Weight:_______ Occupation:___________________________________

Posture assumed most of day (sitting? standing? leaning over? stooped?):


_________________________________________________

Please answer the following questions in as much detail as you can. If you need more
room use the back of this form.
Daily activities, sports, hobbies:
________________________________________________________________________
________________________________________________________________________

Reason for today's visit? (Relaxation? Muscle Tension, etc?)


________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Have you had a massage before? What did you enjoy about it?
________________________________________________________________________
________________________________________________________________________

Were you referred by a doctor or health care provider? (circle one): YES NO

If YES, please explain circumstances:


________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please circle any areas of tension/ pain/ discomfort in the list below:

Head/face Upper Back Buttocks


Neck Mid Back Legs
Shoulders Low Back Knees
Chest Abdomen Feet
Arms/ Hands Hips

List any areas you'd like special attention given to during the massage? (neck, feet, shoulders? Etc?):
________________________________________________________________________

Are there any areas that you would prefer NOT be massaged? (feet, face? Etc.?)
________________________________________________________________________

Please circle any items you are currently wearing:

Contact lenses Pacemaker


Dentures Hairpiece
Hearing aid Other: ___________________________

Are you experiencing any of the following today?: If yes please circle the condition:

Bruises or tendency to bruise easily Warts


Open sores or cuts Allergies or Sinus problems

Is there any chance that you are pregnant?: (circle one): YES NO

Please list medications, supplements, vitamins or other therapies you are currently using:
________________________________________________________________________
________________________________________________________________________

Do you have difficulty lying on your stomach or back for at least 30 minutes? (circle one): YES NO

Is there anything I need to know to ensure your comfort about any of the following?
(please circle, and then we will discuss):

Allergies/ sensitivities Scents


Oils/ Lotions Other:….
Medical History
Please indicate, by placing an x in the appropriate box, if you now have, or have ever had, any of the
following conditions….
Skin Conditions Musculoskeletal Conditions
Have Had Have Had
Now Previously Now Previously

Boils Fi bromyalgia
Erysipelas My ofascial
Pain Syndr ome
F ungal I nfections (Athlete's S hin S plints
F oot, ringworm, Etc.)
Herpes S prains/ Strains
Impetigo Fr actures / Brea ks

W arts Osteopor osis

Acne N/A Dislocations

Eczema Joint Pain / Stiffness

Hives Hypermo bile Joints

M oles Gout

Psoriasis Lyme Disease

Ski n Ca ncer Osteoarthritis

Respitory System Conditions R heumatoi d Arthritis

Have Had TMJ


Now Previously
Bro nchitis B unio ns

C old N/A Plantar Fascitis

I nfl uenza B ursitis

Pne umonia Hernia

Si nusitis Tendonitis

Tuberculosis W hiplash

Asthma Car pal Tunnel

C hronic Bro nchitis Herniate d Disc

Emphysema Thorasic Outlet Syndrome

L ung Cancer Reproductive System Condit ions

Chro nic Cough Have Had


Now Previously
Endocrine System Condit ions Cervical Ca ncer
Have Now Had Previously Dysme noria

Dia betes Endometriosis

Hy perthyroi dism Fibroi d Tumors

Hy pothyr oidism Breast Cancer

Hy poglycemia Ovarian Cancer

Prostate Ca ncer

Pelvic I nflammatory Disease

Pre gna ncy

PMS
Nervous System Conditions Circulato ry System Condit ions

Have Had Have Had


Now Previously Now Previously

Alzheimer's Disease Anemia


Multiple Sclerosis Em bolism/ Thr ombosis/ Bloo d Clot
(DV T)
Parki nson's P hlebitis
Peri pheral Ne uropat hy Hematoma
Tremors Hemo phelia

Meni ngitis Leukemia

Bell's Palsy Clotting or bleedi ng probl ems

Spinal Cord Injury Ane urysm

Stroke Atherosclerosis

Seizures Hy pertension ( high bloo d pressure)

He adaches Low Bloo d Pressure

Migr aine hea daches Ray naud's Syndr ome

Tension headaches Varicose Veins

Cl uster hea daches He art Disease

PMS hea daches He art Attack

Stress Heart Failure

Sleep Disorders Other H eart Co nditions

Anxiety Lymph and Immune System


Conditions
Chemical Depe nde ncy Have Had
Now Previously
De pression Edema

Eating Disorder Lymphoma

History of Mental Ill ness Mononucleosis

Digestive System Conditions Chro nic Fatigue Sy ndrome

Have Had Fever N/A


Now Previously
Indigestion HIV/AIDS

Constipatio n / Diarr hea Lupus

Chro n's Disease Epstein Barr

Refl ux Disorder Urinary System Condit ions

Stomach Ca ncer Have Had


Now Previously
Ulcers Kidney Stones

Appendicitis Renal Failur e

Colorectal Ca ncer Bladder Ca ncer

Div erticular Disease Interstitial Cystitis

Irritable Bowel Syndrome Urinary Tr act Infection (U TI)

Ulcerative C olitis

He patitis

Cirrhosis

Gallstones
Do you have now or have you previously had any cancers not listed above? Circle one: YES NO
If yes please list:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Please list any past surgeries with date:


________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Is there anything else I should know about your health?


________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Is there anything else I should know that will make you more comfortable?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
client agreement
I understand that massage therapy provided by Blue Owl Massage therapy is non sexual.

I understand that massage therapy provided by Blue Owl Massage Therapy is for the purposes of
stress reduction, pain reduction, relief from muscle tension, increasing circulation, or specific reasons
noted here if applicable:

I understand that massage therapy does not diagnose illness or disease, or any other disorder, and
that the massage therapist does not prescribe medical treatment or pharmaceuticals.

I understand it is my choice to receive massage therapy. I am aware of the benefits and risks of
massage and give my consent for massage.

I know that massage therapy is not a substitute for medical examinations or medical care, and that it
is recommended that I am concurrently working with my primary caregiver for any condition I may
have.

I have stated all of my known physical conditions, medical conditions, and medication, and I will keep
the massage therapist updated with any changes.

Signature: Date:
____________________________________________ ______________________

Common questions

Powered by AI

For clients with fibromyalgia, the therapist should consider using a gentler approach with lighter pressure to avoid exacerbating pain. Fibromyalgia is listed under conditions that the client might currently have or have had previously, which suggests that awareness of such conditions is crucial to avoid causing harm or increasing discomfort during the massage . The therapeutic approach should be communication-driven, ensuring comfort and responsiveness to any adverse feedback during the session .

The questionnaire gathers comprehensive information on the client's health conditions, daily activities, areas of pain, and past experiences with massage. This inclusive data collection allows therapists to tailor the session to address specific health needs by avoiding contraindicated techniques and focusing on methods beneficial to the client's unique physical state . This customization ensures a safe and effective session, building trust and enhancing therapeutic results .

Providing detailed medical history on a massage therapy intake form ensures the therapist is informed about any existing health conditions that could affect the safety and effectiveness of the massage. For example, knowing about conditions like osteoporosis, recent sprains, or phlebitis can help tailor the massage to avoid exacerbating these issues . It also allows for better communication between the client and therapist, enabling personalized care that addresses specific needs or limitations due to medical history .

Understanding a client's exposure to stress or anxiety allows therapists to prioritize relaxation techniques and environments that promote mental calmness. It may involve using soothing music, aromatherapy, or adjusting massage pressure to induce relaxation. Addressing emotional conditions holistically enhances the overall therapeutic impact, focusing on both physical relief and mental tranquility .

Disclosing medications or supplements is crucial because certain drugs can affect how the body responds to massage therapy. For example, blood thinners can increase bruising risk, while muscle relaxants might lead to incorrect assessments of muscle tension. Understanding these factors enables therapists to adjust their techniques appropriately, enhancing client safety and achieving the desired therapeutic outcomes .

The client's preferences for certain areas to be massaged and others to be avoided help shape the session’s focus and flow. Attention is concentrated on areas where relief is desired, enhancing client satisfaction and therapeutic benefit. Respecting non-preferred areas ensures comfort and maintains trust, crucial for effective therapy and client-therapist rapport .

Transparency about the non-medical nature of massage is emphasized by explicitly stating that massage does not diagnose or treat medical conditions or replace medical care. Clients are informed that the therapy aims at stress and pain reduction rather than medical treatment. This transparency helps set clear expectations and reinforces the importance of medical consultation for health issues .

Client feedback about previous massage experiences helps therapists understand what the client enjoyed and any adverse reactions they may have had. This information guides the therapist in refining techniques to either replicate positive outcomes or avoid negative ones. It supports personalized care, ensuring each session is progressively adjusted to meet client preferences and therapy goals .

Understanding a client's daily activities helps a massage therapist identify areas of potential muscle tension or discomfort that are related to repetitive motions or sustained postures. For instance, a person who spends most of their day sitting may have tension in their lower back or shoulders. This knowledge allows the therapist to target those areas specifically, enhancing the therapeutic benefits of the session .

The options for areas of discomfort, such as the head, neck, shoulders, or back, guide the therapist in focusing on regions that require attention. By understanding these areas, therapists can apply specific techniques, such as deeper pressure or particular strokes, to alleviate pain and enhance muscle relaxation. Special attention to these areas supports targeted therapy and improves the client’s overall experience and outcomes .

You might also like