About this template
This Reflexology and Massage Consultation Form is designed to gather crucial client health history, lifestyle factors, and specific treatment preferences prior to a session. Perfect for massage therapists, reflexologists, wellness centers, and holistic practitioners, this intake template ensures you have all necessary medical background and emergency contact details before commencing any bodywork.
The form covers essential intake information including existing health conditions, previous injuries, stress levels, daily water intake, lifestyle habits, and targeted treatment goals. By collecting these details digitally ahead of time, practitioners can review client needs in advance, tailor personalized treatment plans, and eliminate clunky paper clipboards in the reception area.
Built for seamless mobile use, clients can easily complete the questionnaire on their phone or tablet before arriving at your studio. Practitioners can instantly review responses, keep records organized, and provide a safer, more tailored therapeutic experience from the very first appointment.
Key features
- Collect comprehensive medical history and lifestyle data securely
- Identify contraindications, allergies, and pregnancy status safely
- Pinpoint client pain points and session goals in advance
- Fully mobile-friendly for easy completion on smartphones
- Instantly generate a ready-to-use Google Form in seconds
Use cases
- Initial intake for new massage therapy clients
- Pre-session health screening for reflexology treatments
- Wellness center and spa client onboarding
- Mobile massage practitioner client registration
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Select your date of birth.
- Phone Number (Short answer)Best number to reach you regarding appointments.
- Email Address (Short answer)Where we can send your appointment confirmations and receipts.
- Emergency Contact Name and Phone (Short answer)Provide the name and phone number of someone we can contact in an emergency.
- Primary Goal for Today's Visit (Paragraph)What are you hoping to achieve from today's session? (e.g., stress relief, lower back pain relief)
- Have you received professional massage or reflexology before? (Multiple choice)Choose one.
- Medical History and Health Conditions (Checkboxes)Select any conditions that apply to you currently or in the past.
- Health Conditions Details (Paragraph)Please provide more details on any checked health conditions or other relevant medical issues.
- Are you currently pregnant? (Multiple choice)Certain treatments are contraindicated during early pregnancy.
- Known Allergies (Short answer)List any allergies to oils, lotions, nuts, or latex.
- Current Medications (Paragraph)List any prescription medications, vitamins, or supplements you are currently taking.
- Current Stress Level at Work and Home (Linear scale)Rate your general day-to-day stress level on a scale from low to high.
- Client Declaration and Consent (Short answer)By typing your full legal name below, you confirm that the information provided is accurate to the best of your knowledge and you give consent to receive treatment.
FAQ
How do I share this consultation form with my clients?
Once generated in Google Forms, you can share the link via email confirmation, text message, or embed the form directly on your booking website so clients fill it out before their appointment.
Can I edit the questions to fit my specific massage practice?
Yes! Because the template lives in your Google Drive as a standard Google Form, you can fully customize, add, or remove any questions to match your exact clinical or holistic practice requirements.
Is this form mobile-friendly for clients?
All Google Forms automatically adapt to mobile screens, allowing your clients to fill out their consultation details effortlessly on their smartphones or tablets.
How do I access client responses?
All submissions are saved automatically in a linked Google Sheets spreadsheet associated with your form, giving you an organized log of client medical histories and contact details.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.