Is Your Health Intake on the Mark?

By Cindy Williams
[Classroom to Client]

You can learn a great deal by receiving massage from other massage therapists and observing how they manage their practices. Checking out a variety of practitioners can be professionally educational on every level. For example, I’ve received many enjoyable massages, but I haven’t received consistent, thorough intake processes. Often this process is too brief, even with an injury present. As a result, clients don’t get what they need and practitioners aren’t doing informed work. It’s worth evaluating why an intake process is important and whether yours is on the mark.

Be Thorough, No Matter What
Whether a client is an athlete, dad, soon-to-be mom, kid, or grandma, their bodies are responding and changing. People experience stresses and challenges—positive and negative. Doctors prescribe new medications. Diets change. Exercise routines ebb and flow. The more a therapist knows about a client’s current state of health, the better they can serve the client. Many factors are involved in how a client is feeling. Following is a guide to ensure you are keeping up with clients’ essential information and effectively supporting them, even in straightforward wellness massages.

The Initial Session and Intake Form
Here are some things to be addressed during a client’s first visit.
Contact Information
The first step in filling out an intake form is gathering contact information. In addition to the client’s name, address, phone number, and email address, be sure to get an emergency contact. You likely won’t need it, but if you do, you’ll be glad you have it. A primary health-care provider’s name and number is good to have for all clients, too, and is essential when working on someone with an illness or chronic condition. When health providers work together and share information (with consent, of course), the circle of care is enhanced.

Current Health Information
This section of the intake form is most effective when a body map is included. Visuals help clients better convey what they are feeling and sensing in their bodies. Using symbols, such as a circle around an area that sometimes hurts and an X on an area that is causing pain or distress, is simple and useful. The more complex the setback, the more specific your notating symbols should be. Have colored pencils on hand and ask clients to draw on the body map using their choice of colors and symbols. The results can be insightful.
 Providing an area for current and past medical conditions is also important; it helps you observe overall stress in the body—even if the injury was long ago. Old patterns create new patterns, so being aware of possible root causes can help unravel the discomfort.

Far too frequently, this section of the health intake is missed. When a client takes medication, a physiological process is altered. Massage may or may not interact negatively with the drug, but what if it can and the therapist doesn’t know about it? Most core massage programs don’t spend a significant amount of time teaching students about pharmaceutical interactions and massage therapy. It pays to do your research. One great resource is Jean M. Wible’s Drug Handbook for Massage Therapists (Lippincott Williams & Wilkins, 2008). Include frequency and dosage information in your intake, because in cases such as diabetes and Parkinson’s disease, the timing between the client’s dose and your massage can make a difference; this is also the case with pain-relieving medications, which are all too commonly used. For more information on medication and massage, read “Medications Matter” in the July/August 2014 issue of Massage & Bodywork, page 92.

The purpose of this section is to understand how your client lives. How much exercise do they get and what kind? What type of work do they do? Do they spend their days sitting, standing, driving, etc.? The information a client gives you about their general day-to-day activities will illuminate their movement patterns, which will help you better formulate the session. This is the case even in a simple relaxation massage. Include a place to list any limitations the client has due to pain or stress. Even if a client has a neck crick, it helps to know that, so you can ask them to perform the restricted movement and see how the rest of their body moves. Simple sessions are made exceptional by adapting the work to the observed pattern.

Recurrent Sessions

For returning clients, here are the intake processes you should follow.
Every Session
It’s always important to request a health update. Every single session needs to include a 3–5-minute discussion dedicated to what the client is currently experiencing. Have this conversation before the client gets on the table. Don’t underestimate the importance of a dedicated check-in. Something could get overlooked that could otherwise inform you. Most clients want to discuss what’s ailing them and what’s causing stress. This might mean booking an hour client with a 10–15-minute cushion between clients. Keep it focused. Questions you might ask include:

• “How did you feel after the last session?”
• “Did your neck pain (or whatever you last worked on or are working with) improve, worsen, or stay about the same?”
• “Was there a technique that felt good and useful?”   
• “Have your medications changed?”
• “What aggravates pain/discomfort?”
Use your best judgment based on the client, with the intent of being effective and educated for your client’s best outcome. Be sure to write everything down, preferably in SOAP charting format, so you can refer back in subsequent sessions and observe improvements, setbacks, or changes of any kind.
Every 6–12 months
Once or twice a year, have clients fill out a new health intake as if they are a first-time client. Updated records protect you should a client claim a negative reaction during or after the session.

On the Mark
Whether your client receives massage for wellness reasons (such as relaxation, stress relief, and to maintain levels of health) or for therapeutic reasons (such as recovery from an injury or illness), consistently practicing a thorough intake process is paramount to your approach and their outcomes. The intake process will vary in depth depending on the purpose of the session and health conditions, but the details presented here should never be skimmed over. Honestly evaluate your processes and forms until you find a combination that is right for you and your clients.

Since 2000, Cindy Williams, LMT, has been actively involved in the massage profession as a practitioner, school administrator, instructor, curriculum developer, and mentor. She is the school education manager for ABMP and continues to maintain a private practice as a massage therapist and yoga instructor. Contact her at