Massage Therapy Client Intake

Online Intake Form

All information is held in 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.

Please Complete Below:

Full Name

First NameMiddle NameLast Name

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number

Area CodePhone Number

This is my:

E-mail

example@example.com

Emergency Contact

Phone Number

Area CodePhone Number

Occupation

Medications

Allergies

Health History

Are you experiencing any signs/symptoms of COVID in the past 14 days, have you been tested positive for COVID in the last 14 days or have you been in contact with anyone who has tested positive in the last 14 days?

1. What is your main reason for your visit today?

2. Are you in discomfort or pain? When was the first onset of pain?

3. Rate of Pain Today

4. What makes the pain feel worse?

5. Have you ever had any surgery for this condition or any other surgeries?

6. Have you been seen by a medical doctor for this condition?

7. Do you have a diagnosis for this condition from a medical doctor? Have you had any treatment for this condition by any healthcare professional? (Ex. Chiropractic, Physiotherapist, Massage etc.)

8. Are you a professional athlete or performer? Are you presently in/off season or live performing? In practice, rehearsals etc.? Please explain.

9. Is there a medical team or therapist on staff?

10. What are your exercise or recreational activities? (including frequency).

11. What other areas do you have discomfort, pain or are a concern for you?

12. Is there anything else you would like me to know prior to your session?

Consent for Care

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give consent for massage. I understand there is no implied or stated guarantee of success or effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions and injuries that I am aware of and will inform the massage therapist of any changes in my health status and new injuries. If I experience pain or discomfort during my session, I will inform the massage therapist so adjustments can be made to my comfort level. 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.

By my signing the electronic signature below, I hereby waive my therapist from any and all liability past, present and future sessions provided by James Giacinto LMT.

Signature

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