Massage Scribe
Intake forms tend to grow. A therapist adds a question after an awkward session, adds another after reading something online, and three years later new clients are filling in two pages of boxes in the waiting room while the session start time slides past.
A good intake form is shorter than most, and every question on it earns its place by changing something: what you do, what you avoid, or who you refer to. Here is what belongs, what does not, and why the form matters more than it looks like it does.
What the form is actually for
Three jobs, and it helps to be clear about which question serves which.
Safety. Finding out what would make your normal approach a bad idea. Blood thinners, recent surgery, uncontrolled blood pressure, pregnancy, skin conditions, recent injury. These questions are the reason the form exists.
Consent. A record that the client understood what the session involves and agreed to it. This is the part therapists most often treat as a formality, and it is the part that matters most if something goes wrong.
Context. What they want, what they have tried, how they respond to pressure. This makes the first session better and gives you a baseline to write your first note against.
What to include
Contact and basics
- Name, phone, email
- Date of birth, which matters for consent age and for context
- Emergency contact
- How they heard about you, which is optional but genuinely useful for knowing what is working
Health history
Ask about current and recent, not everything that has ever happened. A list that stretches back to childhood is noise.
- Current medical conditions
- Current medications, with a specific prompt about blood thinners
- Recent surgery or injury, with rough dates
- Pregnancy, including how far along
- Skin conditions, open wounds, recent infections
- Allergies, especially to oils, lotions, and latex
- Previous massage experience and how they responded
A free text box asking whether there is anything else you should know is worth including. People disclose things there that no checkbox would have caught.
Areas of concern and goals
- What brought them in, in their own words
- Where the problem is, and how long it has been there
- Pain rating if there is pain
- What they want from the session, which is often different from the complaint
- Pressure preference
- Any area they do not want worked on
That last question does a lot of quiet work. It gives people a way to set a boundary in writing, before they are on the table and feel awkward saying it out loud.
Consent
What the session involves, draping and privacy, that they can stop or change anything at any time, and how their information is stored. Then a signature and date. Keep it in plain language. A consent paragraph nobody can parse is not really consent.
Ask whether they have been cleared by a physician, where it is relevant. For pregnancy, recent surgery, or an active medical condition, having their answer in writing changes your position considerably, and it prompts a conversation that is easy to forget to have.
What to leave off
Every field you collect is data you are then responsible for protecting. Some common additions are not worth that trade.
Social security or national insurance numbers. You do not need them, and holding them makes you a target.
Full medical history going back decades. Ask about what is current and relevant. If something historical matters, it will come up in the free text box or in conversation.
Detailed mental health history. Sensitive, mostly outside your scope, and rarely changes what you do with your hands. If a client wants you to know something, they will tell you.
Insurance details, unless you actually bill. Collecting policy numbers you never use is pure liability.
Anything you would not be comfortable explaining. If you cannot say what a question changes about the session, it should not be on the form.
Intake without the clipboard
Massage Scribe creates a single use intake link you send to a client before their first visit. They fill it in on their own phone, it lands in your review queue, and the details carry straight into their client record. Links expire after fourteen days and work once.
See the features Free plan available. No card needed to start.Paper or digital
Paper is simple and works when the wifi does not. It also has to be locked up, it is easy to lose, and it means transcribing the same information twice, once onto the form and once into your records.
Digital forms sent before the appointment solve the two most annoying problems: the client is not filling in health history while your session clock runs, and the information does not need retyping. They also tend to get more honest answers, since people disclose more on their own phone at home than on a clipboard in front of you.
Whichever you use, the storage requirement is the same. Client health information needs to be kept confidential and secure, which means a locked cabinet or software with real access control, not a shared drive or a notes app.
Keep it current
Intake is not a one time event. A client who filled in a form two years ago may have had surgery, started a new medication, or become pregnant since. You do not need a new form every visit, but you do need a habit.
The simple version: ask at the start of every session whether anything has changed since last time, and record the answer in the Subjective section of your note. That single question catches most of it. For regular clients, a full re-intake once a year is reasonable.
How intake connects to your notes
The form is the first entry in the client's record, and it sets the baseline everything else is measured against. A first session note that says pain is 6/10 only means something because the intake established that this is new, or that it has been going on for eight months, or that they tried physiotherapy first.
A useful habit is to carry the important intake details forward into your notes rather than leaving them buried in a form you filed. If a client takes a blood thinner, that should influence what you write in Objective every single session, because it influences your pressure every single session. The worked examples show what that looks like in practice, and the blank templates prompt for it directly.