Thai Body Balance Intake Form

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.
Name*

First NameLast Name
Phone Number
E-mail
Age*
Emergency Contact
Phone Number
Referred by / How do you know about us?
Medications
For woman: Are you pregnant?
Have you ever received therapeutic massage before? If so, how recently?
What types of massage do you prefer?

Chillin' it (Swedish Relaxation)Pain Killer (Deep tissue/Ashiatsu+Thai)Sticks and Stones (Warm Bamboo and Hot Stone Massage)Head Over Boots (All of the above)Other
What level of pressure do you prefer?

lightmediumfirmOther
What are your goals/expected outcomes for receiving massage?
History of Pathology
List Areas of Discomfort or Pain
Have you ever been in an accident (automobile, work, falls, etc.) ?
List all related treatments received for this injury.
Is there anything that you do that creates, increases or decreases pain?
What are the physical duties required of your occupation?
Please check any symptoms that apply to you and indicate right or left when applicable:
Head

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
Neck

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
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Arms & Hands

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

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

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
Hip

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
Legs and Feet

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
Is there anything else about your health history that you think would be useful for your massage therapist to know to plan a safe and effective massage session for you?
Massage Policies: Client services and chart information are confidential. Written authorization is required from you to release any information.
• 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
• 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 Thai Body Balance and my 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*

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Date*

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