Northern Arizona Massage Therapy New Client Intake Form

New Client Intake Form
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
Your Birthday*

MonthDayYear
May we add you to our email list?
May we add you to our texting list?
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
How do you prefer for Northern Arizona Massage Therapy to contact you? *
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about us?*

FacebookGoogle SearchReferral (type name below)
Have you ever received a professional massage before?

YesNo
How often do you like to get a massage/bodywork?
When was your last massage or bodywork?
What is more important to you?*
A deep, therapeutic massage can leave you feeling sore for a day or two. How do you feel about being sore after your massage?*
What would you prefer during your massage session? *
Do you have any areas of sensitivity (ticklishness, tenderness) you prefer your therapist avoids during this and any follow up sessions?
In order to achieve treatment goals, your therapist may deem it appropriate to work on muscle or connective tissue in the inner thighs, buttocks, abdominal region, chest, face, or feet. Please check the areas below you prefer your therapist avoid during this or any other sessions.

FaceFeetChestAbdominal RegionButtocksInner Thighs
I consent to the treatment of the unchecked areas listed above if my therapist deems it appropriate for my treatment goals.*

AgreeDisagree
What level of pressure do your prefer during your massage?*

Deep all overDeep in problem areas, medium elsewhereMedium all overMedium in problem areas, light elsewhereLight all over
What are your top priorities to be addressed at your appointment?

Low Back PainSciatic PainNeck PainHip PainTight Glutes (Butt Muscles)Shoulder IssuesTension Headaches
What are your current issues & how are they affecting you (when do you experience them, do they prevent any of your usual activities ie. sleep work exercise)?
What type of pain are you currently experiencing?*

Stabbing PainElectrical Pain (Sharp Electric Shock)Burning PainAchy PainWidespread Pain & TendernessMuscle SpasmsTension PainSharp Pain, Localized, Small AreaNone
How did your issue/pain begin?*

SlowlySuddenlyIt has gotten worse over time.It has improved over time.I'm not sure how it happened or how it progressed.N/A I do not have an issue or pain.
Please list all surgeries with approximate dates:
Please list any significant head injuries, like concussions, being knocked unconscious, or traumatic brain injury.
Please list any significant injuries to your joints, muscles, or bones.
Do you have any special needs?
Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
What is your due date?
Please describe any complications during your pregnancy ie. Gestational diabetes, Placenta previa, Pre-eclampsia.
Please list all medications you are currently taking:
Medical History: If you have experienced any of the items marked with an asterisk (*), massage may be contraindicated. Please answer honestly, this is to ensure your safety and well-being.

Medical History*

	Current	Past	Never
Blood Clots*
Pacemaker*
Congestive Heart Failure*
Unexplained Calf Pain*
Varicose Veins*
Stroke or Heart Attack*
Cancer*
Car Accident*
High Blood Pressure
Low Blood Pressure
Epilepsy / Seizures
Chronic Headaches / Migraines
Chronic Dizziness / Ringing Ears
Digestive Disease (IBS, Crohns, etc)
Chronic Constipation
Chronic Diarrhea
Kidney Disease / Chronic UTI's
Arthritis (rheumatoid, osteoarthritis)
Scoliosis / Kyphosis / Lordosis
Osteoporosis
Degenerative Spine / Disk
Broken Bone
Allergies that Require an Epi-Pen
Autoimmune Condition (Celiac, Hashimotos, Lupus, Graves, etc)
Diabetes / Insulin Resistance
Endocrine / Thyroid Condition
Chronic Depression
Chronic Anxiety
Chronic Swelling
Sensitive to Touch / Pressure
Easy Bruising
Shortness of Breath / Asthma
Chronic Muscle / Joint Stiffness
Chronic Muscle / Joint Pain
Chronic Pain
Chronic Numbness / Tingling
Neurological Condition (ALS, Parkinsons, etc)
Chronic Skin Rash
Highly Sensitive to Certain Smells or Fragrances
Fibromyalgia
Multiple Sclerosis
Memory Loss / Confusion

Cancellation Policies: 50% Payment will be collected in case of a Last-Minute Cancellation/Reschedule/No Show. Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 50% of the scheduled appointment fee unless we are able to fill the opening. Payment is due before your next appointment.

Late Arrival: If you are late to your session you are welcome to receive whatever time is left in your appointment. Due to our tightly booked schedule we are generally unable to extend your session beyond your original appointment time. Regardless of the length of the service actually given, you will be responsible for payment of the full service you scheduled. Please plan to arrive 10 minutes early for your appointment.
Fragrance-Free Policy Northern Arizona Massage Therapy asks for all clients to refrain from wearing perfume, cologne, after-shave, scented lotions, body sprays or other similar "smelly" products on the day you visit us. Synthetic chemicals found in scented products can trigger migraines and asthma attacks in our sensitive clients.
Smoke-Free Policy Smokers are asked to please shower before your appointment and avoid smoking until after your appointment; this helps us avoid the smell of smoke in our office, which triggers migraines and asthma attacks in our most sensitive clients.
Sickness Policy Please reschedule your appointment as soon as you are aware of an infectious or contagious condition. If you arrive for your appointment with symptoms of an illness, you will kindly be asked to reschedule your appointment to avoid the spread of germs. This protects are most susceptible loved ones - children, the elderly, & people with suppressed immune systems, like cancer patients. Even if you are cancelling your appointment within the 24-hour notice period, the cancellation fee may be waived.
Informed Consent
By typing my first name, last name, and providing my e-signature below, I am indicating the following:

I have read the New Client Intake Form for Northern Arizona Massage Therapy LLC in its entirety. I fully understand all questions and information provided in the New Client Intake Form for Northern Arizona Massage Therapy LLC. I have completed the New Client Intake Form for Northern Arizona Massage Therapy LLC accurately and to the best of my knowledge.

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware.

I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.
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