Client Health History Intake Form

Barefoot Massage Health Intake Form

All information is held in the 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 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 *
E-mail *
Emergency Contact *
Phone Number *
How did you hear about us? Facebook, Instragram, TikTok, Google, Radio, our sign, or a friend, if so who? *
Occupation
Medications
Allergies
Health History
Age, Height & Weight *
Please ✓ then explain at the bottom any of the following conditions that apply. *

New Tattoo Topical/Nut Allergies Rashes Cellulitis Infection Fungus Athletes Foot Psoriasis Ringworm Infectious Disorders NONE
Reproductive *

Pregnant Nursing Trying to Conceive Currently menstruating Recent procedures NONE
Joints/ Bones *

Stiffness Pain Inflammation Disslocation Degeneration Joint disease Bone Spurs Osteopenia / Osteoporosis Tendonitis / Bursitis Arthritis / Gout NONE
Surgeries Augmentation / Implants When? *
Musculoskeletal

Muscle pain or weakness Cramping or Spasms Neck Injury or Whiplash Carpel Tunnel Syndrome, Thoracic Outlet Syndrome NONE
Bones / Foot

Broken Bone Plantar Fasciitis Bunion Neuroma Bone Spur Plantar Warts Athlete’s Feet NONE
Circulatory / Cardiovascular *

Blood Clots or Blood Thinning Meds Aneurism Phlebitis Varicose Veins Heart Conditions Stents/Shunts NONE
Nervous System Neurological Condition *

Sciatica Numbness Decreased sensation Loss of Motor Control Shooting Pain Tingling Stroke NONE
Autoimmune *

Lupus Multiple Sclerosis Fibromyalgia Flared? NONE
Circulatory/ Cardiovascular *

Pacemaker Low or High Blood Pressure High Cholesterol Hemophilia Poor Circulation / Reynauds Epilepsy Seizures Fainting NONE
Eye / Optical issues *

Optical Nerve Issues Eye Surgery Lasik Currently Wearing Contacts NONE
Injections / Shots *

Cortisone Epidural Steroid Nerve Blocks Trigger Point Injection None
Metal/ Hardware *

Laminectomy Rods Fusions Screws / bolts / pins / plates Cages Joint replacement NONE
Hernia *

Abdominal Hiatal Inguinal NONE
Spine Issue *

Coccyx injury Scoliosis Spondylolethesis Spondylitis Stenosis Degenerative Disc Disease NONE
OTHER *

Diabetes Cancer Lymphatic issues / Edema NONE
Please Explain Any Above Checked Items *
Please list all Supplements & Medications *
List Areas of Focus, Discomfort or Pain to be addressed at during the massage *
Claint Waiver Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent to massage.

I understand that there is no implied or stated guarantee of sucess of effectiveness of individual techinques or select appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any chanes in my health status.

I understand that massage therapy is for stress reduction, relaxation, relief from musclear tension and improvement of circulation and energy.

I understand that massage is entirely therapeutic and non-sexual in nature. By signing this release, I hearby waive and release my therapists from any and all liability, past, present and future relating to massage therapy and body work.
Signature *

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

Month Day Year
Date
Cancelation Policy

We offer the option to cancel with a minimum 24 hours prior of scheduled appointments with full credit toward another service scheduled at the time of cancelation. Clients can cancel and schedule via call, text, email or within our online scheduling system. If clients cancel within less than 24 hrs of their appointment a cancelation fee will be charged to their credit card saved to our scheduling system. Once an appointment time passes the service is no longer eligible for rescheduling and the client forfeits the cost of the services. We will not be able to bill insurance for these services so the client will pay in full at our medical massage rate for thier missed appointment.
Signature *

Clear
Date *

Month Day Year
Date
Contract for Care

I will partipcate fully as a member of my healthcare team. I will make sound choices regarding my sessions plan based upon the information provided by my massage therapist. I agree to participate in my own self-care programs and adhere to the plan we select. I agree to communicate with my practitioner anytime I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of his or her skills and knowledge.
Signature *

Clear
Date *

Month Day Year
Date
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