New Client Intake. First Name Last Name. Address. City State Zipcode Date of Birth. Home Phone Mobile Phone. Relationship to you Phone

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Transcription:

1 New Client Intake Address City State Zipcode Date of Birth Home Phone Mobile Phone Emergency Contact: Relationship to you Phone Please explain the pain you are experiencing and its origin story: https://docs.google.com/document/d/1q0tns8lwtefzbbj1n9jyt2onopvy2abs9s1ofr07zai/edit 1/5

2 Are you allergic to any lotions or oils? Yes No Please circle your stress level: Low 1 2 3 4 5 High Are you presently taking any medication? Yes No Have you had a recent major surgical procedure or injury? Yes No Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue? Yes No https://docs.google.com/document/d/1q0tns8lwtefzbbj1n9jyt2onopvy2abs9s1ofr07zai/edit 2/5

3 Check all the following conditions that apply to you, past and present. Musculo-Skeletal Conditions Headaches Joints sti ness/swelling Spasms/cramps Strains/sprains Broken/fractured bones Back, hip pain Leg, foot pain Chest, ribs, abdominal pain Osteoporosis Problems walking Shoulder, neck, arm, hand pain Jaw pain/tmj Tendonitis Bursitis Arthritis Scoliosis Other Circulatory/Respiratory Conditions Dizziness Shortness of breath Fainting Cold feet or hands Cold sweats Stroke Heart condition Allergies Asthma High blood pressure Low blood pressure Other Digestive Conditions Indigestion Intestinal gas/bloating Constipation Diarrhea Irritable bowel syndrome Crohn s Disease Colitis Other Nervous System Conditions Numbness/tingling Fatigue Sleep disorders Ulcers Parkinson s Disease Herpes/shingles Cerebral Palsy Chronic Fatigue Syndrome Epilepsy Multiple Sclerosis Muscular Dystrophy Paralysis Other Reproductive System Conditions Pregnancy Other Skin Conditions Rashes Allergies Athlete s Foot Acne Impetigo Other Other Conditions Loss of Appetite Di culty concentrating Depression Hearing impaired Visually impaired Diabetes Fibromyalgia Post/Polio Syndrome Cancer Tuberculosis Other https://docs.google.com/document/d/1q0tns8lwtefzbbj1n9jyt2onopvy2abs9s1ofr07zai/edit 3/5

4 Agreement By signing my name below, I understand that a massage Therapist does not diagnose disease or illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand that draping will be used at all times and that breast massage will not be administered on female clients. I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the massage session, and they will end the session. I understand that the massage Therapist may end the session for any inappropriate behavior. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status. Agreement: By signing below, I agree to the terms and conditions above. Signature Date https://docs.google.com/document/d/1q0tns8lwtefzbbj1n9jyt2onopvy2abs9s1ofr07zai/edit 4/5

5 Consent for Therapy and Waiver of Liability Client understands and agrees that they will provide the Therapist with complete and accurate health information, and a written referral from Client s primary healthcare provider if Client is currently receiving care or has a specific medical condition or symptoms for which Client takes medication or receives periodic evaluations or treatment. Client understands that massage therapy is designed to be an ancillary health aid and is not suitable for primary medical treatment for any condition. 1. Client and Therapist have discussed the potential benefits and possible side e ects of massage therapy and have agreed upon a course of focused attention and manually therapy for the predetermined goals of stress reduction, relief of muscular discomfort, and/or promotion of general health. Client has been given an opportunity to ask questions of the Therapist and has received all requested information. 2. Client agrees to immediately inform the Therapist of any unusual sensation or discomfort so that the application of pressure may be adjusted to Client s level of comfort. Client understands that massage therapy is not sexual in any manner and that any illicit or suggestive remarks or behavior on the client s part, will result in an immediate termination of the therapy session. Client understands that payment will be expected in full; regardless if the massage is completed or not. 3. Client hereby assumes full responsibility for receipt of the massage therapy, and releases and discharges Therapist from any and all claims, liabilities, damages, actions, or causes of action arising from the therapy received hereunder, including, without limitation, any damages arising from acts of active or passive negligence on the part of the Therapist, to the fullest extent allowed by law. 4. Client, in signing this consent for Therapy and Waiver of Liability ( Consent ), understands and agrees that this Consent will apply to and govern the current and all future therapy sessions performed by Therapist. Agreement: By signing below, I agree to the terms and conditions above. Signature Date https://docs.google.com/document/d/1q0tns8lwtefzbbj1n9jyt2onopvy2abs9s1ofr07zai/edit 5/5

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