Aberdeen Massage: New Client Intake Form NEW

Lotus & Sage Wellness

1112 Lancaster Bypass W, Suite 2

Lancaster, SC 29720 803-287-9257
New Client Intake Form
Name*

First NameLast Name
Gender*
Phone Number*

Area CodePhone Number
Email*
How do you prefer for Lotus & Sage Wellness to contact you? *
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about us?*

FacebookInstagramGoogle SearchReferral (type name below)Other
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? *
What are your top priorities to be addressed at your appointment?*

Low Back PainSciatic PainNeck PainHip PainTight Glutes (Butt Muscles)Shoulder IssuesTension HeadachesOther
What are your current issues & how are they affecting you?*
What type of pain are you currently experiencing?*

Stabbing PainElectrical Pain (Sharp Electric Shock)Burning PainAchy PainWidespread Pain & TendernessMuscle SpasmsTension PainSharp Pain, Localized, Small AreaNoneOther
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.Other
In your entire lifetime, have you ever had any of the following surgeries?*

Any Orthopedic SurgeryCarpal Tunnel SurgeryRotator Cuff SurgeryNeck / Back FusionKnee SurgeryHip ReplacementAnkle SurgeryGallbladder SurgeryHysterectomyAppendectomy (Appendix Removal)Breast SurgeryLymph Node RemovalOther
Please list all surgeries:
HEAD INJURY: Please list any significant head injuries, like concussions, being knocked unconscious, or traumatic brain injury.*
BODY INJURY: Please list any significant injuries to your joints, muscles, or bones. *
Do you have any special needs I should prepare for?
Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
Which prescription medications are you currently taking?*

I am NOT taking any prescription medications.I just take Aspirin for my heart.I take a blood thinner medication.Other
Medical History: If you have experienced any of the symptoms that is marked with an asterisk (*), please call Kelsey to discuss your medical history before booking an appointment; this is to ensure your safety and well-being.

Medical History*

	Current	Past	Never
Pregnancy*
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 100% Full Payment is required for the following conditions: No Show: If you do not show up for an appointment, you will be charged the full cost for the appointment. 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 5 minutes early for your appointment. 50% Payment may be required for the following condition: Last-Minute Cancellation or Reschedule: Failure to cancel or reschedule your appointment at least 24 hours in advance ccan result in a charge of 50% of the scheduled appointment fee. Payment is due before your next appointment. Thank you for understanding.
Special Consent for Massage of Inner Thighs, Gluteal Muscles (Buttocks), & Pelvic Floor What are these areas? Inner thighs: adductor muscles Buttocks: gluteal muscles, piriformis, upper and lateral sacrum Pelvic floor: ischial tuberosity, sacrotuberous ligament, coccyx, lower sacrum Why work these areas? Many times, pain or discomfort in the lower back is due to issues with the muscles in the buttocks, inner thigh, and pelvic floor regions. Client Education = Empowerment In order to achieve treatment goals, your therapist may deem it appropriate to work on muscle or connective tissue in the inner thighs, buttocks, and pelvic floor regions. Please let your therapist know immediately if at any time treatment feels uncomfortable in any way.
Consent for Massage of Inner Thighs, Gluteals, & Pelvic Floor Region*
Informed Consent
By typing my first name, last name, and providing my e-signature below, I am indicating the following: 1. I have read the New Client Intake Form for Lotus & Sage Wellness LLC in its entirety. 2. I fully understand all questions and information provided in the New Client Intake Form for Lotus & Sage Wellness LLC. 3. I have completed the New Client Intake Form for Lotus & Sage Wellness LLC accurately and to the best of my knowledge.
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First NameLast Name
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