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Intake Form
Full Name
Email Address
Sex
Female
Male
Birthdate
Home Address
Occupation:
Primary Physician: (optional)
Emergency Contact:
Emergency Contact Relationship:
Emergency Contact Phone:
How did you hear about us?
Are you taking any medications?
Yes
No
If Yes, please indicate below:
Any surgeries in the past year?
Have you had any orthopedic injuries?
Yes
No
Are you currently pregnant?
Yes
No
If yes, how far along:
Do you suffer from chronic pain?
Yes
No
Any high risk factors?
Body Issues to Address
Head
Neck
Upper Back
Lower Back
Shoulder
Left/Right Arm
Hips
Left/Right Thigh
Legs
Foot
Describe Sensation(s)
Cause of injury or concern
How long since first noticed
Do you have any existing conditions?
Asthma
Shortness of Breath
Bronchitis
Chronic Cough
Emphysema
Blood Clots
High Blood Pressure
Varicose Veins
Congestive Heart Failure
Phlebitis
Heart Attack
Lymphedema
Heart Disease
Myocardial Infarction
Cold Hands
Pacemaker
Cardiovascular Accident
Low Blood Pressure
Cerebral-vascular Accident
Stroke
Cold Feet
Thrombosis/Embolism
Bruise Easily
Hypersensitive Reaction on Skin
Skin Conditions
Skin Irritations
Melanoma
Ear Problems
Headaches
Hearing Loss
Jaw Pain (TMJD)
Migraines
Sinus Problems
Vision Loss
Vision Problems
Athlete's Foot
Hepatitus
Herpes
Respiratory Conditions
HIV
Gynecological Issues
Pregnancy
Cardiovascular Conditions
Respiratory Conditions
Burning
Tingling
Cerebral Palsy
Multiple Sclerosis
Numbness
Stabbing Pain
Parkinsons
Herniated Disc
Allergies
Dizziness
Mental Illness
Anaphylaxis
Epilepsy
Osteoarthritis
Artificial Joints/Special Equipment
Fibromyalgia
Osteoporosis
Arthritis
Gout
Cancer
Hemophilia
Surgical Pins or Wire
Crohn's Disease
Insomnia
Rheumatoid Arthritis
Diabetes
Loss of Sensation
Shingles
Digestive Conditions
Lupus
Other Diagnosed Diseases
Other Medical Conditions
Are there any other conditions that is not listed above? If yes, please specify:
COVID-19 SYMPTOMS
Please check the box below if any of the following are true:
Have had a fever within the last 24 hours
Recently experienced respiratory/flu symptoms, sore throat, or shortness of breath
Contact, within the last 14 days, with anyone diagnosed with COVID or related symptoms
COVID Symptoms Questionnaire
I have no symptoms
Have you had a professional massage before?
Yes
No
What pressure do you prefer?
Light - Medium
Medium - Medium Deep
Deep
Do you prefer a quiet massage or do you enjoy conversation?
Do you want the table warmer on or off during your massage?
What are your goals for this treatment session?
Is there any past treatments done? If yes, please specify
Client Waiver Form
I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
I affirm that I have notified my therapist of all known medical conditions and injuries.
I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist's part should I forget to do so.
I understand that massage is entirely therapeutic and non-sexual in nature.
I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19.
By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
Signature accepted, submit form to complete.
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