MASSAGE Therapy Client Intake

Massage Client Intake Form

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

First NameLast Name
Birth Date

MonthDayYear
Phone Number*
E-mail*
Emergency Contact*
Occupation
RELEVANT MEDICAL INFORMATION

Please check/answer any areas you'd like your therapist to be aware of:
CancerHeadaches/MigrainesArthritisDiabetesJoint ReplacementHigh/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsSprains or StrainsNumbnessOther
Allergies
Medications
MASSAGE BODY AREAS

Please check any areas you'd like your therapist to work on or be aware of:
Head

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther
Mid-Back

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Hip

Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Legs and Feet

Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
Do you have any other relevant information for your therapist?
Are there any areas you DO NOT want touched?
LIABILITY WAIVER

Please read the following and sign below:
Precautionary Coronavirus Liability Release:

Due to the outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitizing and disinfecting practices. Please complete the following and sign below.

Symptoms of COVID-19 include, but not limited to:

Fever, Fatigue, Dry Cough, Difficulty breathing, Chills, Nausea or vomiting, Diarrhea, Confusion, Muscle Pain, Headaches, Red or Purple Toes, Loss of Taste, Bruising, Cramping in Lower Legs.

I agree to the following: I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. I affirm that I, as well as all household members, have not been diagnosed with COVID19 within the last 30 days. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days. I understand that this business (Bloom Wellness LLC), landlord (Finkler Enterprises LLC) and my massage therapist cannot be held liable for any exposure to the virus or any other contagion passed on via massage therapist, employees, other customers in the space, or general shared use of the space or Equipment.

By checking the box below, I agree to each above statement and release the massage therapist, and Bloom Wellness from any and all liability for the unintentional exposure or harm due to COVID-19. Your massage therapist and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitization protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

Client Agreement:

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 acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

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

By my electronic signature below, I agree to the Coronavirus Liability Release & Client Agreement above.
Signature*

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