New Client Intake Form
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
Referred By
*
Google
Facebook
Instagram
Friend/Family
Other:
If Friend/Family or Other, please name below:
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
General Medical History Information
Have you ever received any kind of bodywork (chiropractic, massage, etc.)
*
Yes
No
If yes, how frequently?
*
List any current medications, along with reason for taking:
*
List any surgeries/hospitalizations, along with aprx. date:
*
List any allergies (medicines, seasonal, etc.):
*
Do you have any of the following?
*
AIDS/HIV
Auto Immune Disorder
Asthma
Blood Clots
Bone/Joint Disorder (Arthritis, Osteoporosis, etc.)
Cancer
Connective Tissue Disorder (EDS/Hypermodility, Sjögren Syndrome, RA, etc.)
Digestive Issues (IBS, IBS-C, Leaky Gut, etc.)
Headaches/Migraines
High Blood Pressure
Low Blood Pressure
Lymphedema
Mast Cell Activation Syndrome
Numbness/tingling/burning
Poor Circulation
POTS
Varicose Veins
Neurodivergence (Autism, ADHD, etc.)
Other
Daily Water Intake
*
Daily Caffeine Intake
*
Describe Your Diet:
Type & Frequency of Movement:
*
General Lifestyle Information
Type & Frequency of Self Care:
*
Describe your sleep quality:
*
On a scale of 1 to 10, rate your stress level:
*
1=little stress, 10=incredibly stressed
On a scale of 1 to 10, rate your energy level:
*
1=little/no energy, 10=high energy
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Areas of Active Pain or Concern
If you have chronic pain areas/injuries (existing longer than 3 months), please make note of that below.
Describe your primary areas of pain or concern:
*
How did your symptoms begin; when did they begin?
*
On a scale of 1 to 10, rate your pain/discomfort level:
*
1=little/no pain, 10=unbearable pain
Are you interested in home care suggestions & information (i.e. stretches, self massage techniques, movement modification suggestions, etc.)?
Yes, I am committed to working on my areas of pain/concern at home.
No, I am only interested in receiving massage.
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Sensory & Overall Comfort Needs
Check each of these as "overall" or "general" supports. I will always check-in with you the day of our session to see what needs are acutely present.
Table warmer
Plushy Blanket - moderate weight
Light Blanket - light weight
My music
Your own music
No music
My lotion (BioTone Advanced Therapy Lotion - non greasy/hypoallergenic)
Your own lotion
No lotion (this typically looks like deep pressure through the blanket and top sheet -or- skin-to-skin with no glide, light stretching of the skin to access the myofascial system (myofascial release))
Light pressure (lymphatic drainage)
Medium Pressure
Deep Pressure
Other
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Therapeutic Massage Waiver Form
Please take a moment to read & digitally initial all of the following statements:
If I experience pain or discomfort of any kind during the session,
I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort
.
I
recognize that it is my responsibilty to communicate with my therapist my needs & expectations
; I will not hold my therapist responsible for any pain or discomfort during or after the session.
I understand that the services offered today are intended to be in support of medical care;
I understand the services are
not a subsitute for medical care
.
I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, perscribe, or treat physical or mental illness.
I affirm I have notified my therapist of all known medical conditions, emotional/mental conditions, and PTSD triggers, injuries (past/present), and (past/present) surgeries.
I agree to
inform my therapist of any changes in my health and medical conditions, emotional/mental conditions, and PTSD triggers, injuries (past/present), and (past/present) surgeries
I understand that there shall be no liability on my therapist's part should I forget to do so.
I understand that massage is entirely therapeutic and non-sexual in nature.
By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future, relating to massage therapy, bodywork, emotional distress related to pre-existing mental/emotional disorders .
CANCELLATION POLICY
I understand that, should I cancel an appointment
less than 24 hours before the scheduled time
or "no show" for an appointment,
I will be charged full price of the session booked.
If the appointment was booked with a gift certificate, it will be voided in lieu of the fee.
Signature
*
Date
*
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Month
-
Day
Year
Date
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