Massage Health Intake Form Please complete the form below if this is your first bodywork experience with us. Name * First Name Last Name DOB * MM DD YYYY Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Occupation How did you find me? * Emergency Contact (Name, Relationship, Phone) Are you currently taking any medications? * Yes No If yes, please list name and use: Do you have computer implants such as a pacemaker, insulin pump or spinal stimulator? * Yes No Are you currently pregnant? * Yes No Planning to be If yes, how far along? Do you suffer from chronic pain? Yes No If yes, please explain: Have you had any recent injuries or surgeries? If so, please explain what type of injury/surgical procedure and it's cause/reason. Please indicate any of the following that apply to you: Headaches / Migraines Stress Anxiety Arthritis Diabetes Cancer Joint Replacement High/Low Blood Pressure Neuropathy Fibromyalgia Digestion Issues Stroke Seizure Heart Attack Numbness Kidney Dysfunction Blood Clots Depression Joint Pain Sinusitis Dizziness Fatigue Abdominal Pain Bloating Hernia / Rupture Varicose / Spider Veins Osteoporosis Skin Condition Autoimmune Disorder Other (please explain below) How would you describe your general health? * It isn't the best. I struggle often. It is okay, but not as good as it could be. I try to maintain good health. I consider myself healthy. How would you describe your lifestyle? Consider: Dietary Habits, Exercise Habits, Rest, Stress Levels, Emotional well being, Work-Life Balance, Overall Happiness + Satisfaction. Do you take in high amounts of any of the following? Caffeine (4+ servings per day) Nicotine (5+ cigarettes/vape breaks) Alcohol (7+ drinks per week) Fast Food (2+ times per week) Water (64 ounces/half a gallon per day) Have you had a professional massage before? Yes No What type of pressure do you prefer? Light Medium Deep I'm unsure Do you have any allergies or sensitivities? * Yes No If yes, please explain: Do you now, or have you recently had any respiratory or flu symptoms? * Yes No Have you had a fever in the last 24 hours? * Yes No Have you been in contact with anyone in the last 14 days who has had COVID-19 symptoms? * Yes No Would you prefer your practitioner to wear a mask during your appointment? I have no preference, without is just fine. Yes, please! What are your goals for this treatment session? * I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. * Please Initial. I understand that all treatments at this facility are therapeutic in nature. I agree to notify the therapist of any physical discomfort or draping issues during the session. * Please Initial. I understand that, because massage therapy involves maintained touch and close proximity over an extended period of time, there may be elevated risk of disease transmission, including COVID-19. * Please Initial. This facility has provided me with information on MediCupping™ therapy (if this is a part of your session). If I choose to experience this therapy in my treatment, I understand the effects and after-care recommendations. It has been explained to me that there is the possibility of a skin discoloration, or 'cup kisses' appearing as tissue is released. I am aware that a 'cup kiss' is not a bruise and that it will dissipate within a few hours to a few days. This facility and the therapist will not be held liable for indications that arise during or after the treatment, and I agree to notify the therapist if there is any discomfort during a session. * Please Initial. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner. I acknowledge that this facility and the therapist will not be held liable for indications that arise during or after the treatment, and I agree to notify the therapist if there is any discomfort during my session. * Please type your full name. Cancellation Policy Acknowledgement * I acknowledge this business's 24-hour cancellation policy stating that should I cancel within 24 hours of my reserved appointment time, or that if I do not show up, I am still responsible for paying for 100% of the service I had scheduled. I understand Thank you!
