Massage Therapy Client Intake

Client Intake Form All information is held 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 NameMiddle NameLast Name

Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number*

This is my:*

E-mail*

Emergency Contact*

Phone Number*

Occupation

Medications

Allergies

History of Pathology

1. Are there any specific areas of the body that need to be addressed in this session?*

2. Rate of Pain Today*

3. Have you ever injured this area before3*

4. Have you ever been in an accident (automobile, work, falls, etc.) ?*

5. Have you ever received therapeutic massage for a specific problem or injury?

Was the treatment used effective?

6. Is there anything that you do that creates, increases or decreases pain? *

7. What are the physical duties required of your occupation?*

8. What activities/hobbies do you enjoy?*

9. Please list exercise and stress reduction activities (including frequency).*

10. Are you currently seeing any other healthcare professional?

11. What type of pressure do you prefer?*

12. Do you like essential oils?*

13. Do you prefer a heated table?*

14. Is this your quiet time? *

15. Are there any areas you'd like to avoid?

16. How did you hear about Ashley Masters Healing Arts?*

Massage Policies: Client services and chart information are confidential. Written authorization is required from you to release any information. • Please turn off your cell phone for optimal relaxation • Your scheduled session is set aside for you. We do not double book appointments • Please reschedule your session if you are more than 15 minutes late • 24 hour cancellation notice is required to avoid being charged 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 • I understand that my therapeutic massage therapist or I may end the session at any time for any reason • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law 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 treatment given is designed to address the care and prevention of myofascial pain and dysfunction. 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 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 post a threat to my health and/physical well being and I hold harmless Pure Touch Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part. By my electronic signature below, I agree to the massage policy and client agreement above.

Signature*

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