YMHA of North Jersey Massage Wellness Center
Client Intake Form
The following series of questions are to familiarize the therapist with important
information about you, the client. It is of the utmost importance that you take the time to
answer these questions to the best of your ability. This will help the therapist meet your
massage needs. Please notify your therapist of any changes in your medical condition.
All information is confidential.
Day Phone: Evening Phone:
City: State: Zip Code:
Date of Birth: Occupation:
Membership Number: Status (circle one): HC G NM Valley
Massage and Stretch History
Have you ever received a professional massage? Circle one: Yes No
If yes, how often? Date of Last Massage:
What types of massage/bodywork have you had?
What results do you want from your massage session(s)?
What is your major concern today?
Desired Pressure? Circle one: Light Firm Deep
Prioritize the areas of your body that you would prefer to be massaged:
Please circle the areas of your body that you give permission to receive massage:
Back Legs Buttocks Arms Abdomen Pecs/Chest Neck Head Face Other___________
Age Group (Circle One): 18-30 31-40 41-50 51-60 Over 60
NOTE: The YMHA of North Jersey does not serve clients under the age of 18.
Are you currently under the care of a physician? Circle One: Yes No
NOTE: Some diagnoses may be contraindicating for massage therapies, if you are uncertain of your
condition please contact your physician and Massage Director before booking an appointment.
If yes, please explain:
Please list any recent injuries, illnesses, or surgeries:
List current medications, including aspirin, ibuprofen, vitamins, herbs, etc:
Do you have chronic or frequent pain? Circle One: Yes No
FEMALE CLIENTS ONLY: Are you pregnant? Circle One: Yes No
If yes, how many months? ___________
Please contact the Director before scheduling an appointment because some pregnancies are
high risk and may require your physician’s approval for having a massage.
Circle One Option Per Item
Contact lenses Yes No Diabetes Yes No
Dentures Yes No Phlebitis/Blood clots Yes No
Ulcer Yes No Infectious diseases Yes No
Spinal problems Yes No Heart problems Yes No
Tendonitis, bursitis, etc Yes No Hi/Low Blood Pressure Yes No
Osteoporosis Yes No TMJ Yes No
Arthritis or Joint Disease Yes No Migraines/Headaches Yes No
Broken bones Yes No Immovable Joints (Joint Replacements) Yes No
Diabetes Yes No Back Problems Yes No
Easy bruising Yes No Cold Hands/Feet Yes No
Seizures/Convulsions Yes No Sciatica Yes No
Skin problems Yes No Sinus Problems Yes No
Multiple Sclerosis Yes No Neck Problems Yes No
Allergies Yes No Fibromyalgia Yes No
Nerve degeneration Yes No Cancer or Tumors Yes No
Varicose veins Yes No Type ____________________________________
Any other medical condition(s) the therapist should be aware of? Yes No
If Yes, please explain:
Do you exercise regularly and/or participate in any sports? . . . . . . . . . . . . . . . . Yes No
If yes, which sports?
Have you recently suffered an injury? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ….. .Yes No
If yes, describe:
Have you had any areas of inflammation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . …. . Yes No
If yes, describe:
For your convenience and to save time on the day of your appointment, please print and
complete all three (3) pages of this form and bring it with you. Or you may prefer to email this
form prior to your appointment. To do this: Highlight, copy and paste all three (3) pages into
your “word” program, then type the appropriate information into the form. Email the completed
form to firstname.lastname@example.org. You can sign it upon your arrival. Thank you!
Massage Release Waiver
• I understand that massage therapy and bodywork are for the purposes of stress
reduction, relief from muscular tension and spasm, general relaxation, and improvement
of circulation and energy flow.
• I understand that the bodywork practitioner does not diagnose illness, disease, or any
other physical or mental disorder. The practitioner does not prescribe medical treatment
or pharmaceuticals, nor does he/she perform any spinal manipulations. It has been
made very clear that massage therapy and bodywork are not substitutes for medical
examination or diagnosis and that it is recommended that I see a medical practitioner for
any physical ailment that I may have.
• I understand that services offered today, and in the future, are not a substitute for
medical care and that any information provided by the therapist is for educational
purposes only, and is not diagnostically prescriptive in nature.
• I have stated all of my known medical conditions on the Intake Form. I have consulted a
medical doctor or licensed medical health care practitioner regarding these conditions.
• I realize it is solely my responsibility to keep the bodywork practitioner updated on any
changes in my physical health and I understand that YMHA of North Jersey and the
practitioner shall not be liable should I fail to do so.
• I agree to actively participate, as much as possible, in my own healing and health
• I understand that all massage therapy and bodywork offered is strictly non-sexual.
• By signing this release, I hereby waive and release from any and all liability, past,
present, and future, relating to massage therapy and bodywork.
• I have received the policy statement, and have read and agree to the policies therein.
Signature of Client ___________________________________ Date_____________________