MT Intake Form

Soulrenity Wellness Spa & Boutique, LLC

218 E. Lexington St., Ste. #504

Baltimore, MD 21202

Massage Therapy Intake Form

All information is held in the strictest of confidence. At no given point will information be disclosed or shared with third parties without the client’s written consent. Please answer each question to the best of your knowledge. Providing accurate information helps us to better plan your treatment of care.
Date *

Month Day Year
Full Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth

Month Day Year
Phone Number *
Best Contact Number
E-mail *
example@example.com
How did you hear about us?
In Case of EMERGENCY *

First Name Last Name
Phone Number *
Best Contact Number
Medications
Allergies
Any chance that you could be expecting? *
When was your last massage?
Do you have any treatment goals for today's Self Care Session?
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 Other
5. At what time of day is the pain at its worse? *

Morning Afternoon Evening During Sleep Other
6. Have you ever injured this area before? If Yes, please explain. *
7. Have you ever been in an accident (automobile, work, falls, etc.)? If so, when? *
8. List all related treatments received for this injury and any recent injuries or surgeries, if applicable.
9. Have you ever received therapeutic massage for a specific problem or injury? If so, please explain.
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? *
15. Are you currently seeing any other healthcare professional? If Yes, please explain.
Do you have any skin conditions, open cuts, wounds or bruises? *
Any previous dislocated or broken bones? If so, please explain. *
Any past head trauma? If so, please explain. *
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 Other
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 Other
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 Other
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 Other
Mid-Back

Mid-back pain Pain between shoulder blades Pain up/down back Pain across mid back Pain with breathing Other
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 Other
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 Pain in quads Pain in hamstrings Diagnosed bursitis Diagnosed arthritis Other
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 Other
Any past/present history with any of the following?

High blood pressure Diabetes Bruise easily Depression Insomnia Anxiety Blood clots HIV/AIDS Cancer Headaches Epilepsy/Seizures Varicose veins Frequent stress Joint swelling Arthritis Cardiac/Circulatory problems Back pain Numbness/Stabbing pains Sensitive to touch/pressure Tension/soreness in any specific area Contagious diseases COVID19 Concerns laying face down Concerns with closterphobia Aversions to heat Dentures Contact lenses Currently grieving the loss of a loved one Other
Massage Therapy Session Policies:

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

• Masks are to be worn before, during and after your session

       • Please turn your cell phone to silent for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments, therefore please arrive 15min prior to your scheduled session

       • Please reschedule your session if you are more than 10 minutes late. Please plan accordingly

***If you are feeling sick or recovering from being sick/ill, please reschedule for a later date no less than 2wks later from your original appointment***

       • 6 hour cancellation notice is required to avoid being charged a cancellation fee of $35 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 and proceed to get under the blanket and the sheet of the massage table

• Inappropriate behavior be it gestures, touching or speech will not be tolerated and your appointment will be discontinued immediately and you may be prosecuted to the full extent of the law

• We do not offer REFUNDS

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.

It is my choice to receive therapeutic massage as a form of therapy.

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

I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction, to provide relaxation and an overall feeling of well being.

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 can 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 pose a threat to my health and/physical well being and I hold harmless Soulrenity Wellness Spa & Boutique, LLC, it's board, associates, partners, independent contractors, affiliates, employees, representatives, successors and my therapeutic massage therapist from any liability whatsoever arising from failure to do so on my part.

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

Month Day Year
Date
Signature *

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear
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