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Therapist of the Month: Gonzalo Reategui
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Therapist of the Month: Jennifer Sahy
Massage of the Month
Kenneth Lewis
COVID-19 / Treatment Consent Update
We have updated our intake form. All current and new clients must complete this form prior to receiving any services.
If you prefer,
HERE
is a downloadable/printable version of our intake form
.
1
Personal Info
2
Massage History
3
Health History
Personal Info
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone (Cell or best contact number)
*
Phone (Secondary contact - not required)
Email
*
Occupation / Employer
Primary Care Provider
Primary Care Provider Phone
Emergency Contact
*
First
Last
Emergency Contact Phone
*
Massage History / Treatment Information
Have you ever received a professional massage?
*
Yes
No
Date of last massage
MM slash DD slash YYYY
What results do you want from your sessions?
Please check any areas of your body where you prefer not to receive massage:
Head
Face
Neck
Arms
Chest
Abdomen
Back
Buttocks
Legs
Feet
Other
Other
Are you currently seeing a healthcare practitioner?
*
Yes
No
Please describe:
List stress Reduction and Exercise Activities. Please include frequency.
List current Medications, Herbals & Supplements and reason for use. Please Include OTCs such as Aspirin, Ibuprofen, Claritin, etc.
Previous History
Surgeries (Include year and treatment received)
Accidents (Include year and treatment received)
COVID-19 Information
1. Have you had a fever in the last 24 hours of 100°F or above?
*
Yes
No
2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
*
Yes
No
3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
*
Yes
No
Health History
Musculoskeletal
Bone or Joint Disease
Tendinitis / Bursitis
Broken / Fractured Bones
Arthritis / Gout
Jaw Pain / TMD
Lupus
Sprains / Strains
Low Back, Hip, Leg Pain
Neck, Shoulder, Arm Pain
Headaches, Head Injuries
Spasms/Cramps
Other
Other
Circulatory
Heart Condition
Varicose Veins / Phlebitis
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombus / Embolism
Other
Other
Respiratory
Breathing Difficulty / Asthma
Emphysema
Sinus Problems
Allergies
Other
Specify Allergies
Other
Nervous
Herpes / Shingles
Numbness / Tingling
Pinched Nerve
Other
Other
Reproductive
Pregnant
Ovarian / Menstrual Problems
Prostate
PMS
Other
If pregnant, Trimester:
Other
Skin
Allergies
Rashes
Athletes Foot
Herpes / Cold Sores
Warts
Other
Specify Allergies
Other
Digestive
Constipation
Gas / Bloating
Diverticulitis
Irritable Bowel Syndrome
Ulcers
Other
Other
Other
Cancer / Tumor
Diabetes
Chronic Fatigue
Chronic Pain
Eating Disorders
Sleep Disorders
Bladder / Kidney Ailment
Drug / Alcohol Addiction
Caffeine / Tobacco Addiction
Migraines / Headaches
Anxiety / Stress Syndrome
Depression
Contact Lenses
Consent and Contract for Care
It is my choice to receive massage therapy or yoga, and I give my consent to receive treatment. I have completed this form to the best of my knowledge and will inform the massage therapist or yoga instructor or any changes in my physical health. I understand that massage therapist and yoga instructors can not diagnose illness, disease, or any other medical, mental, or emotional disorder. Nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I realize that the treatment is being given for the well being of my body, mind and spirit. This includes stress reduction, relief from muscular tension, spasm or pain, also for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my wellbeing is compromised. I acknowledge that massage and yoga are not substitutes for medical examinations or diagnosis; I am responsible for consulting a qualified physician for any physical ailments that I have. I understand that massage therapy and yoga is a therapeutic health aide and is non-sexual.
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 agreeing to this statement, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.
Consent
*
By checking this box I agree to the above statement.
X
