An intake form does one job on the day and a different job three years later. On the day it tells you what to ask about before you start. Later it is the record showing that you asked at all.
Most forms are built for the first job only, which is why they collect a lot and record little.
The fields, and what each is for
Contact details and date of birth. Identifies the file, and flags when a client is a minor, which changes both who consents and how long the record must be kept.
Reason for today’s visit. Sets the session, and gives you the client’s own words to carry into the Subjective field of your note.
Current medications. Some affect bruising, blood pressure, sensation or how a client responds to pressure. You are not assessing the medication. You are noticing that it is there so you can ask the follow-up.
Injuries and surgeries, with rough dates. Recent is a different situation from old, and a date lets you ask rather than guess. “Shoulder surgery” tells you little; “shoulder surgery, about eight weeks ago” tells you what to do next.
Ongoing conditions the client wants you to know about. Worded as an open invitation rather than a tick-list. A checklist of named conditions invites people to tick nothing, and it quietly implies you are screening for that fixed set.
Pregnancy. Changes positioning, so ask it directly rather than inferring it.
Areas to avoid. The single most useful line on the form, and the one clients most often fill in unprompted. It also catches things people would not raise under a medical heading.
Pressure preference. Cheap to ask, and it prevents the most common first-session complaint.
How they heard about you. Not clinical, but it is the only marketing data a solo practice reliably gets.
Anything past that needs a reason. Every extra field costs attention from the fields that matter, and a long form gets filled in carelessly.
Writing the consent section
Consent needs to say what the client is agreeing to, that they may ask questions, that they may decline or stop any part of the session, and that they will tell you if their health changes. Short is fine. Comprehension matters more than length, and a paragraph a client actually reads does more than a page of terms they scroll past.
Two things worth being clear about in your own head:
A signature at intake is general consent. It records agreement to treatment. It does not cover every specific thing you might do in a session two years later.
Specific consent belongs in the day’s note. Where a session calls for work that warrants a particular conversation, such as an area a client has not been worked on before, record that conversation in that session’s record. Consent that lives only on a form signed two years ago is thinner than it looks, and one line in the day’s note is what makes it real. Our SOAP note guide covers where that line goes.
Update, do not overwrite
Health histories go stale. Medications change, injuries happen, pregnancies begin and end.
Ask returning clients to confirm or update at least once a year, and any time they mention something new. The important part is how you store the update: keep the old version rather than writing over it. What was true when you treated someone in 2024 is the record that matters if anyone asks about a 2024 session, and a form showing only today’s answers cannot tell you what you knew back then.
On paper that means a new dated sheet stapled to the old one, not correction fluid. In an app it means versioned intake, which is why SOAP Notes: Massage Client Log stores each update as a new version alongside the previous one rather than replacing it.
After it is filled in
A completed intake form holds health information a client handed you in confidence. Store it somewhere only you can reach, and do not leave completed forms on a clipboard in a shared space.
How long you must keep it varies by state, and several states count from the end of the therapeutic relationship rather than the last session, so a form can outlive the client relationship by years. The rules we have verified against each board’s published source are on our massage record retention by state page.
If you want a starting point rather than a blank page, our free massage intake form template is printable and explains each field as you go.
This is general information, not legal advice, and it does not make any practice compliant with any particular regulation. Confirm intake, consent and records requirements with your own state board.