SPA DAY Client Intake

SPA DAY 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
Phone Number*
Email*
Birth Date

MonthDayYear
Occupation
If Applicable Enter the Following Info for Bloom Deals & Specials
Anniversary Date

MonthDayYear
Date
Are You Celebrating Anything Today?
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:
TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
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
Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
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 painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
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
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
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?
FLOAT THERAPY Relevant Information
YesNo
YesNot Sure
SAUNA PRECAUTIONS

Exposure to infrared waves or elevated body temperature can possibly change the effect of prescription drugs. Additionally, some over-the-counter drugs, such as antihistamines, may also cause the body to be more prone to heat stroke. Some medications may lead to dizziness. Check with your personal physician or pharmacist before using the sauna.

Lotions/Chemicals

Do not use chemicals or lotions prior to your session. These items may block pores and affect perspiration.

Fever/Pregnancy/Menstruation

Individuals who have a fever should not use the sauna until fever subsides. Pregnant women should consult their physician before using an infrared sauna. Heating of the low back area of women during the menstrual cycle may temporarily increase their menstrual flow.

Alcohol

Contrary to popular belief, it is not advisable to attempt to “sweat out” a hangover. Alcohol intoxication decreases a person’s judgment; therefore, he/she may not realize when the body has a negative reaction to high heat. Alcohol also increases the heart rate, which may be further increased by heat stress.

Cardiovascular Conditions/Chronic Conditions

Heat stress increases cardiac output and blood flow in an effort to transfer internal body heat outside via the skin (perspiration) and respiratory system. Those with cardiovascular conditions should take caution when using the sauna. Multiple Sclerosis, Central Nervous System Tumors and Diabetes with Neuropathy are conditions that are associated with impaired sweating.

Individuals with a history or heart disease, high blood pressure, obesity or diabetes should have their blood pressure monitored before and after each session.

Implants/Artificial Joints

Metal pins, rods, artificial joints or any other surgical implants generally reflect infrared waves and thus are not heated by this system. Nevertheless, please consult your physician prior to using the sauna.

Joint Injury

If you have a recent (acute) joint injury, it should not be heated for the first 48 hours after injury or until swelling subsides. If you have joints that are chronically hot and swollen, these joints may respond poorly to vigorous heating of any kind.

*If at any time during your session you feel dizzy or light headed, get out of the sauna and inform spa personnel immediately.
Precautionary Liability Release & Client Agreement:

• I acknowledge that the floatation tank contains Epsom salt (magnesium sulfate) and hydrogen peroxide, and natural enzymes which may produce an adverse reaction in certain people.

• I am choosing to use the floatation tank of my own free will and agree that I will not hold the owner/operator or Bloom Wellness for any injury or other matter occurring during or after a session while on premises. This includes slipping as a result of entering, or exiting the floatation tank. For the purposes of this agreement, Bloom Wellness means Bloom Wellness LLC, and its affiliates and their respective owners, members, employees, agents, contractors and landlords (Finkler Enterprises LLC)

• By the execution of this agreement, I accept and willingly assume full responsibility for any and all injuries including entering and exiting the facility including the parking lot, damages (both economic and non-economic), and losses of any type, which may occur to me or my guest, and I hereby fully and forever release and discharge the company, its insurers, employees, officers, directors, and associates, from any and all claims, demands, damages, rights of action, or causes of action, present or future, whether the same be known or unknown, anticipated, or unanticipated, resulting from or arising out the use proper, or improper of said equipment, and facilities.

Client Agreement:

• I understand that Bloom Wellness does 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 Client Agreements above.
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