CLIENT INTAKE FORM UPDATE

CLIENT INTAKE FORM UPDATE

Waiver Covers Massage Body Work & Energy Therapies and any additional services for operations under/ by any therapist operating out of 444Hands/Bethany Chabot LMT
Please fill out in detail in areas that allow you to input infromation. please be sure to address all areas of concern prior to your visit. This form is an update to be sure to have all files current todate. You must complete one time prior to scheduling.
FIRST NAME*
LAST NAME*
Birthday*
Email*
example@example.com
Address Street Number and if APT Number or PO BOX
City/State/Zip*
Phone:CELL*
Other PHONE NUMBER IF ALSO USED
Occupation*
Referred to This Office By*
In Case of Emergency Contact*
In Case of Emergency Contact RELATIONSHIP*
In Case of Emergency Contact PHONE NUMBER PRIMARY*
In case of Emergency Contact Phone Number Secondary
General and Medical Information.

Please get medical clearance should you have any reason to question receiving massage at this time
Have you ever had a professional massage? Yes/No if Yes please indicate your frequency per year. *
Are you Pregnant?*
If YES HOW FAR ALONG in your PREGNANCY?*
Are you sensitive to touch/pressure in any area? (ticklish?)*
List of current medications and reason:*
List of Surgeries TYPE:*
List of surgeries Date:*

MonthDayYear
Date
List of Surgeries TYPE:
List of surgeries Date:

MonthDayYear
Date
List of Surgeries TYPE:
List of surgeries Date:

MonthDayYear
Date
ANY ADDITIONAL MEDICAL INFO I SHOULD BE AWARE OF:*
Pain/Tension/Lifestyle:

Rate your Overall levels On a scale from 0-10, 0=none or lowest 10=highest. Evaluate yourself in an overall daily/weekly depending on the question.
Stress*
Pain*
Energy*
Workout/Activity Level*
Water Intake Daily*
Nutrition Eating Well*
Fatigue*
Sleep Quality*
Anxiety*
Depression*
Overall Health*
Alcohol/Caffeine/Energy Drinks *
Fill in.

These answers will help me know how best to serve you.
How did your symptoms begin and when did they start?*
What have you done for relief?*
Is the condition getting better/worse*
Skin condition-rash, warts, hives, skin cancer, athletes foot, other*
Lymphatic condition-swollen gland, nasal congestion, lymph edema*
Joint problems/stiffness-arthritis, sacroiliac problems, TMJ, other*
Bone Condition-osteoporosis, fracture, other*
Headaches, Migraines, other*
Circulatory Condition-high blood pressure, varicose veins, blood clots *
Numbness/Tingling, Sciatica, Tendinitis, Bursitis *
Diabetes.If yes are you regulated? Do you have a pump attached? *
Heart Conditions*
Using the diagram above please list the primary reasons you are seeking therapies from 444 Hands. *
ANY RECENT INJURY? If Yes please also list the injury*
If Yes please give date:

MonthDayYear
Date
ANYTHING ELSE I SHOULD BE AWARE OF PRIOR TO TREATMENT?*
Massage Client Intake Form WAIVER SIDE Massage Client Waiver Form. Sign to acknowledge reading and understanding.
Please take a moment to read all of the following statements:

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to do Chiropractic adjustments, (sidenote the therapies used can lead to structural intergation adjustments), diagnose, prescribe, or treat physical or mental illness.

I affirm that I have notified my therapist of all known medical conditions and injuries even if not listed on the first sheet.

I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the 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 and bodywork.

I understand that should I cancel an appointment less than 24 hours before the scheduled time or “no show” an appointment, I am subject to a fee equal to the cost of the missed appointment. This fee is monetary & can’t be taken as an additional “punch” off a massage package card. If the appointment was booked under a gift certificate, it will be voided in lieu of the fee. Please see cancleation policy at check out when booking online as well.
Signature*

Clear
Information and Suggestions
- Prior to your massage, please remove corrective lenses and all jewelry. Pull long hair back with a clip or band.
- In general, massage is given while you are unclothed. However, you may choose to wear undergarments or a swimsuit. You will be covered with a top sheet throughout your session. This is your massage and you should be as comfortable as possible.
- Feel free to ask your therapist any questions before, during, or after the session. Your therapist is a highly trained professional and will be happy to make you feel informed and comfortable.
- Please also see the FAQ section on the website for all other helpful information.
I have received the Waiver statement, and have read and agree to the policies therein.
Client name:*
Client signature:*

Clear
Date:*

MonthDayYear
Date
Therapist signature:

Clear
Should be Empty:

CLIENT INTAKE FORM UPDATE

General and Medical Information.

Pain/Tension/Lifestyle:

Fill in.

Massage Client Intake Form WAIVER SIDE Massage Client Waiver Form. Sign to acknowledge reading and understanding.

Information and Suggestions