Client Intake Form

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name *

First Name Middle Name Last Name
Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date

Month Day Year
Phone Number *
This is my: *
E-mail *
Emergency Contact *
Phone Number *
Occupation
Medications
Allergies
History of Pathology
1. List Areas of Discomfort or Pain *
2. Describe Onset of Discomfort or Pain *
3. Rate of Pain Today *
4. Frequency - please select the most accurate *

Constant Off/On At Rest With Activity
5. At what time of day is the pain at its worse? *

Morning Afternoon Evening During Sleep
6. Have you ever injured this area before? *
7. Have you ever been in an accident (automobile, work, falls, etc.) ? *
8. List all related treatments received for this injury.
9. Have you ever received therapeutic massage for a specific problem or injury?
Was the treatment used effective?
10. Is there anything that you do that creates, increases or decreases pain? *
11. What are the physical duties required of your occupation? *
12. What activities/hobbies do you enjoy? *
13. Please list exercise and stress reduction activities (including frequency). *
14. In what position do you most often wake up? *

Back Side Stomach
15. Are you currently seeing any other healthcare professional?
Please check any symptoms that apply to you and indicate right or left when applicable:
Head

Temples Forehead Top of head In the eyes Entire head Base of skull Dizziness Fainting Light-headedness Pain in ears Ringing in ears
Neck

Stiffness Pain at neck shoulder junction Pain when turning head Pain with side to side movements Neck feels out of place Muscle spasm in neck Gliding/Grating sound with neck movement Diagnosed bone spurs Diagnosed disc herniation
Shoulders

Pain in shoulder Front Back Side Pain deep in shoulder joint Diagnosed bursitis Diagnosed Arthritis Can't raise arm above shoulder level Can't raise arm over head
Arms & Hands

Pain in upper arm Pain in forearm Pain in wrist Pain in fingers Sensation of pins & needles in arm Sensation of pins & needles in fingers Fingers go to sleep Hands cold Swollen joints in fingers Sore joints in fingers Diagnosed arthritis Loss of grip strength
Mid-Back

Mid-back pain Pain between shoulder blades Pain up/down back Pain across mid back Pain with breathing
Low Back

Low back pain Low back pain is worse when working Low back pain is worse when lifting Low back pain is worse when stooping Low back pain is worse when standing Low back pain is worse when sitting Low back pain is worse when bending Low back pain is worse when coughing Pinched nerve in low back Low back feels out of place Pain up/down low back Pain across low back Diagnosed disc herniation
Hip

Pain in buttocks Pain in buttocks when standing Pain buttocks in buttocks when sitting Pain on side of hip Pain deep in hip joint Pain on sit bone Diagnosed bursitis Diagnosed arthritis
Legs and Feet

Pain down RIGHT leg Pain down LEFT leg Pain down BOTH legs Leg cramps Pin & Needles in RIGHT leg Pin & Needles in LEFT leg Numbness in RIGHT leg Numbness in LEFT leg Numbness in RIGHT foot Numbness in LEFT foot Numbness in toes Feet feel cold Cramps in RIGHT foot Cramps in LEFT foot Swollen RIGHT ankle Swollen LEFT Ankle Swollen RIGHT foot Swollen LEFT foot Pain in RIGHT Foot Pain in LEFT Foot Pain in RIGHT knee Pain in LEFT knee Diagnosed Arthritis
Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off your cell phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged for your session

       • You will be draped and at no time will genitalia or breast tissue be exposed

       • You will have a consultation with your therapist to discuss your session

       • Should the session require, after your therapist has left the room, you may disrobe to your comfort level

       • I understand that my therapeutic massage therapist or I may end the session at any time for any reason

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement:

It is my choice to receive massage or Health Consultations as a form of therapy. Due to Covid 19 I am aware of the benefits and risks of being treated in this office and give my consent for treatment / consultation . I take full accountability of my immune function knowing others are treated and sharing this healing space. __________ (initial here if in office)

I have stated that I am free of any symptoms of flu illness, cold symptoms , and or symptoms of covid 19 with no fever. To my understanding I have not been in contact with anyone with Covid 19 within the last 2 weeks or 14 days. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis.___________ (initial here if in office)
I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept on record and file 3 years or unless required by law. I understand and consent that my medical information may be shared by the various careproviders involved in my care and treatment.

I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I understand that treatment given is designed to address the care and prevention of myofascial pain management, dysfunction along with Lymphatic, Swedish, Ayurvedic and Other modalities of the healing arts.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I do not hold Hanusa Msssage Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
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