Client Intake Form - Therapeutic Massage
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- Thomasine Potter
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1 Client Intake Form - Therapeutic Massage Personal Information: Date: Name: Phone #: Address: City/State/Zip: DOB: Occupation: Emergency Contact: Phone #: HOW DID YOU HEAR ABOUT US? The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge. 1 - Have you had a professional massage before? Yes No If yes, how often do you receive massage therapy? 2 - Do you have any difficulty lying on your front, back or side? Yes No 3 - Do you have any allergies to oils, lotions, or ointments? Yes No 4 - Do you have sensitive skin? Yes No 5 - Do you sit for long hours at a workstation, computer, or driving? Yes No If yes, please describe: 6 - Do you perform any repetitive movement in your work, sports, or hobby? Yes No If yes, please describe: 7 - Which area of the body are you experiencing tension, stiffness, pain or other discomfort? Please identify: 8 - Do you have any particular goals in mind for this massage session? Yes No Circle any specific areas you would like the massage therapist to concentrate on during the session:
2 Medical History In order to plan a massage session that is sage and effective, Calm Spirit needs some general information about your medical history. 9 - Are you currently under medical supervision? Yes No 10 - Are you currently taking any medication? Yes No 11 - Please check any condition listed below that applies to you: contagious skin condition phlebitis open sores or wounds deep vein thrombosis/blood clots easy bruising joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis recent accident or injury osteoporosis recent fracture epilepsy recent surgery headaches/migraines artificial joint cancer sprains/strains diabetes current fever decreased sensation heart condition back/neck problems high or low blood pressure fibromyalgia TMJ carpal tunnel syndrome circulatory disorder tennis elbow varicose veins Pregnancy if YES, how many months? atherosclerosis If Yes a Prenatal massage is a specialty. Have you been in an auto accident recently? Yes No Have you been released from your family practitioner to receive massage? Yes No Draping will be used during the session - only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17. I, (print name) understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that my massage therapists is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist undated as to any changes in my medical profile and understand that there shall be no liability on the therapist s or Calm Spirit Acupuncture & Massage. The cost of treatment has been disclosed to me and I understand that payment is due at the time services are rendered. I hereby release Calm Spirit Acupuncture & Massage and any of its employees against any and all liability associated with this procedure.
3 Signature of Client: Date: Signature of Therapist: Date: Informed Consent & Waiver 1 - I understand that massage body workers and holistic practitioners are not medical doctors and do not diagnose illness, disease, or any physical or mental disorder. I acknowledge that massage and alternative holistic therapies are not substitutes for medical treatment, and that Calm Spirit Acupuncture & Massage recommends I see a primary healthcare provider for that service. I understand that it is my responsibility to communicate with my therapist if I have concerns or questions about my session. I do not have any injuries or conditions that would prevent me from receiving a massage, nor have I been told by a health care provider that I should not receive massages or alternative therapies. 2 - I understand that massage therapy and body work services are a therapeutic health aid and are non-sexual. I understand my massage therapist reserves the right to end a therapy session in the case of sexual innuendos or advances from the client. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the massage, and I will be liable for full payment of the scheduled session. Calm Spirit Acupuncture and Massage reserves the right to deny services at any time. 3 - Any information exchanged during a massage or body work session is confidential and is only used to provide me with the best health care services available. I understand that a massage therapist will ask me questions about my health and physical condition and that I am obligated to answer truthfully and honestly about my health history in full detail. 4 - I understand that my feedback is essential in my treatment and that if I experience any unusual discomfort and/or pain during my massage session, it is my responsibility to inform the therapist in order to enable the therapist to adjust the pressure or technique being used. 5 - The therapist reserves the right to decline, discontinue, or restrict services based on any provided information that may indicate that massage therapy would put my health or the therapist s health at risk. 6 - I acknowledge that I am responsible to be on time for my appointment and that the therapist is not under any obligation to extend my therapy session. I also agree that I am responsible to pay for the full time I have booked with the therapist if I am late. I understand that my appointment time is reserved for me only. If I miss an appointment or am unable to give twenty four (24) hours notice I understand I will be charged for my appointment. I agree to pay Calm Spirit Acupuncture and Massage a No Show/Cancellation charge of $ I understand that massage therapy and body work are for the purposes of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow. 8 - I understand that the practitioner does not prescribe medical treatment of pharmaceuticals nor does he/she perform any spinal manipulations. 9 - I understand that services offered today, and in the future, are not a substitute for medical care and that any information provided to me by the therapist is purely for educational purposes and is not diagnostically prescriptive in nature.
4 10 - I have stated all of my known medical conditions on the Client Intake form. I have consulted a medical doctor or licensed medical health care practitioner regarding any checked or described conditions I understand that it is solely my responsibility to keep the therapist updated on any changes in my physical health and I further understand that Calm Spirit Acupuncture & Massage and the therapist shall not be liable for any purpose and for any reason whatsoeve. Acknowledgement Section Client: By signing this Informed Consent and Waiver, I consent to receive therapy at Calm Spirit Acupuncture & Massage and hereby agree to all policies of Calm Spirit Acupuncture & Massage. I waive and release Calm Spirit Acupuncture & Massage and its entire staff, massage therapist, and body work practitioners from any and all past, present, and future liability, loss, cost, claim, or damage whatsoever which may be imposed upon Calm Spirit Acupuncture & Massage relating to massage therapy and body work; including but not limited to reflexology, acupressure, polarity therapy, energy therapy, Reiki, nutritional therapies, all forms of kinesiology, aromatherapy, craniosacral therapy, myofascial release therapy, trigger point therapy, stretching therapy, strength and condition training, among others. I further undertake to indemnify and hold Calm Spirit Acupuncture & Massage harmless from any incident(s) arising from my use of Calm Spirit Acupuncture & Massage services. I agree to and acknowledge the foregoing on this day of, 20. Client Signature: Print Name: Address: Ph#: Parent/Guardian Waiver For Minors: If the client is less than 18 years old, the Client s parent and natural guardian hereby represents that he/she is, in fact, acting in that capacity, has consented to his/her child or ward s availing of the services of Calm Spirit Acupuncture & Massage, and has agreed individually and on behalf of the child or ward, to the terms of this Informed Consent and Waiver. The undersigned partent or guardian further agrees to hold harmless and indemnify Calm Spirit Acupuncture & Massage from all loss, cost claim, or damage whatsoever which may be imposed upon Calm Spirit Acupuncture & Massage relating to massage therapy and body work; including but not limited to reflexology, acupressure, polarity therapy, energy therapy, Reiki, nutritional therapies, all forms of kinesiology, aromatherapy, craniosacral therapy, myofascial release therapy, trigger point therapy, stretching therapy, strength and condition training, among others on behalf of the Client and all of the Client s parents or legal guardians. I agree to and acknowledge the foregoing on this day of, 20. Client Signature: Print Name:
5 Address: PH#: Are You under the age 18? Yes No
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