Campus Massage Intake

First name

Last name

Email

Phone

Date of Birth

Month

Day

Year

Institution / Campus Affiliation

Community Role

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Are you currently taking any medications?

If yes, please list the medication name(s) and their use.

Are you currently pregnant?

Yes

No

Not Applicable

If yes, how far along are you, and are there any pregnancy-related or high-risk factors we should know about?

Do you currently experience chronic pain?

Yes

No

If yes, please describe the pain and what makes it better or worse.

Have you had any orthopedic injuries?

Yes

No

If yes, please list the injury or injuries and any current limitations.

If you selected any condition above, please provide any relevant details, precautions, or current limitations.

Are you currently experiencing a fever, contagious illness, or feeling acutely unwell?

Yes

No

Do you currently have any open wounds, active skin infections/rashes, or areas of inflammation that should be avoided?

Yes

No

If yes, please describe the area(s) and any precautions we should know about.

Have you had surgery or an invasive medical procedure within the past 6 weeks, or are you currently under post-procedure restrictions?

Yes

No

If yes, please describe the procedure, date, current restrictions, and whether you have been medically cleared for massage.

Has a healthcare provider advised you to avoid or modify massage/bodywork, or are you currently under any medical or activity restrictions?

Yes

No

If yes, please describe the restriction(s), recommended modifications, and any instructions from your healthcare provider.

Do you have any allergies or sensitivities relevant to massage products or materials (such as oils, lotions, fragrances, or latex)?

Yes

No

If yes, please list the allergy or sensitivity and anything that should be avoided.

What pressure level do you generally prefer?

Light

Medium

Firm

Unsure — I’d like to discuss with my therapist

Are there any areas you do NOT want massaged or would prefer to avoid today?

Yes

No

If yes, please list any areas to avoid, touch boundaries, or preferences you would like your therapist to know.

What level of conversation do you generally prefer during your massage?

Quiet / minimal conversation

Occasional check-ins

Conversational

No preference

I understand that massage therapy involves professional therapeutic touch, pressure, movement, and/or holding of the soft tissues. I understand the scope and limitations of massage therapy and that it is not a substitute for medical diagnosis or treatment.

I understand that my participation is voluntary and that I may request changes to pressure, positioning, draping, areas being addressed, or may stop the session at any time.

I understand that professional draping and appropriate boundaries will be maintained to protect my safety, comfort, privacy, and modesty throughout the session.

I certify that the information I have provided is accurate and complete to the best of my knowledge. I have had the opportunity to ask questions, understand the nature and purpose of massage therapy, and voluntarily consent to receive massage therapy services.

Client Signature

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Date/Time of Consent

Month

Day

Year

Time

HoursMinutes