New Client Intake - Formstack

First Name

Last Name

Date of Birth

Address Line 1

City

State

ZIP Code

Email

Phone

Occupation

Please list your occupation so your therapist can better understand your needs.

Name of Physician and Phone Number

For collaborative and customized treatment plans, and/or emergency purposes.

What type of physical activity or extracurricular activities do you do and how often?

Any repetitive motion can heavily impact our body and its needs.

Emergency Contact Name & Phone Number

Where did you hear about us?

Google Search Yelp Social Media Other

Were you referred by someone? If so, please list below.

My general wellness is:

Good Fair Poor

Please check if you have any of the following:

Do you currently have any skin conditions, rashes or warts? If so, where?

Do you have arthritis? Where?

Neck Condition

Pain with movement Stiff neck Popping/grinding noises Whiplash None of the above

Have you had any neck injuries? If so, explain where and when.

Head

Sinus/allergies TMJ Grind teeth Light bothers eyes Light-headed Ringing in ears None of the above

Do you experience headaches? Where? Frequency? Usual treatment?

Have you had any recent head injuries? If so, what and when?

Shoulders

Pain when raising arm Pain on rotation Bursitis None of the above

Have you had any shoulder injuries? If so, explain where and when.

Arms and Hands

Numbness/tingling Hands cold Loss of grip strength Shooting pains None of the above

Have you had any injuries to arms or hands? If so, explain where and when.

Back

Upper back pain Middle back pain Lower back pain Disc problems Pain when lifting Pain when sitting Pain when working None of the above

Have you seen a doctor or chiropractor for any of the above conditions? If so, when? What was the result?

Hips, Legs and Feet

Numbness Shooting pains Ticklish feet Hip replacement Knee surgery Sciatica None of the above

Have you had any injuries or surgeries for any of the above checked conditions? If so, when?

Please list any medications you are currently taking.

Are you pregnant or experiencing any abdominal symptoms. If so, please explain.

Please describe any recent illness, broken bones, injuries/surgeries not listed above (including dental surgery), skin allergies, or any other conditions or information you feel we should know.

Please briefly describe your perfect session.

Please describe your perfect pressure. Firm, Medium, Light?

Please describe any disappointment or dissatisfaction regarding ANY previous massage you have received.

Everyone is different and we want to make sure you enjoy a perfect experience that is entirely your own!

Not enough pressure used

Accessed only superficial (top) tissue layers Did not access desired muscle tissue Never experienced this problem

Too much pressure used

Depth was uncomfortable Depth was uncomfortable due to sore, sensitive muscles/areas Depth was uncomfortable due to direct, focused pressure (use of fingers, knuckles, thumbs or elbows) Would have preferred broad pressure using long, soft strokes (use of forearms and palms) Never experienced too much pressure

The pace of the massage was distracting

Repetitive strokes, specifically on one area or another, distracted from relaxation of massage Flow of massage lacked connectivity; experience seemed choppy Pace of therapist’s movement from one body area to another was too fast to promote relaxation Pace of therapist’s movement from one body area to another was too slow to be relaxing Never experienced this problem

Looking to Experience “Good Hurt”

Access varying tissue layers with specific, desired pressure (generally more firm); affects immediate and recognizable relief I am not looking to experience this depth level

Looking for an Experience that “Hits the Spot”

Access varying tissue layers affecting immediate and recognizable relief in a pleasant and relaxing way I am not looking to experience this depth level

Looking to Experience “Relaxation”

I’m just looking to relax Firm pressure is uncomfortable to me I prefer broad pressure with soft, stimulating strokes I am seeking some relaxation along with a style listed above. My visit is goal-oriented only; relaxation is not a priority

From the above image. List any problem areas that you have, or muscles that need specific work during your visit.

Please list any areas you would like your therapist to avoid.

Please describe your pain or discomfort to the best of your ability.

On a scale of 0 to 10, my pain or discomfort is:

My main priority for today’s session is:

Please check one of the following:

I would like a full body massage with some focus work on my problem areas. Relieving pain or discomfort in my problem areas is my main concern. This visit, a full body massage is not necessary. Relief to my main problem areas is my main concern, if time allows, more areas may be addressed.

The purpose of the massage is to provide stress relief, pain control and relaxation. I do not expect, nor will I ask my therapist to diagnose, prescribe for, or treat any of my symptoms. I understand that any relief of physical or emotional symptoms is the product or process that resides in me. The therapist cannot “fix” me.

I understand that I am responsible for my emotions, feelings, body and belongings and that the therapist is responsible only for giving a massage. Control of the session is mine and I can always say, “Stop.” I understand that in order to receive a massage, it is necessary for me to remove my clothes. Anyone receiving a massage will be modestly covered with a sheet at all times as required by law. I understand that massage to the gluteal area or upper/inner thighs is often necessary for achieving requested relief and should in no way be interpreted as a sexual advance. I understand I may request at any time (before or during the massage) that these areas be avoided should massage in these areas make me in any way uncomfortable.

I do not expect, nor will I ask my therapist to discuss or perform a sexual act. I understand that my therapist will not engage in any discussion of a sexual nature and that the massage will be terminated immediately if any verbal or physical sexual suggestions are made. I understand that Indecent Exposure is a misdemeanor offense that will be immediately reported to the police. I understand that my therapist is ethically and legally prohibited from ever engaging in any physical activity or romantic relationship with me or any client of Deep Tissue Boise.

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.

In the spirit of understanding, I agree to hold Deep Tissue Boise, Idaho Wellness Group, and my therapist blameless for any problem that might arise as a result of my massage sessions.

INTOXICANTS

It is the policy of Deep Tissue Boise that, for the safety of the therapist and client, massage services will be denied to clients who consume alcohol or drugs prior to their appointment or who appear to be under the influence of alcohol or drug consumption when they arrive for their appointment. I agree to comply with this policy.

INFECTIOUS CONDITIONS

My therapist is informed about infectious illness and skin conditions and routinely practices to protect himself/herself and others from the spread of disease. Any person who is experiencing abnormal or uncontrollable secretion or excretion of bodily fluids such as bleeding, vomiting, diarrhea, should not receive a massage until the condition is resolved.

Any person who has a contagious condition including, but not limited to, strep throat, flu, chicken pox, measles, staph infection, or an infectious skin condition such as impetigo, should not give or receive a massage until the condition is no longer contagious. Other contagious skin conditions that should be made aware to the therapist include, but are not limited to, cold sores and warts; informing your therapist about these conditions will stop the spread of these conditions to other parts of my body, the therapist, and other clients.

The therapist will use disposable gloves, a finger cot or adhesive bandage if the skin on her hands is not intact due to cuts, burns, abrasions, chapping, or damaged cuticles.

I Have Read and Agree to all of the above Informed Consent:*

Signature *

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The City of Boise has laid out necessary guidelines for safely practicing massage during covid-19. The following guidelines will be upheld in order ensure we are able to stay open for you and all our clients in the Treasure Valley.

1. Please Check Your Temperature Before Arriving. Your appointment should be rescheduled if your temperature is 100.4 or above. Exposing your therapist to fever and other covid-19 symptoms could put your therapist at risk, and therefore any clients that follow. Arriving with symptoms also threatens the safety of the other therapists at Idaho Wellness Group including their clients.

2. Reschedule if you are experiencing even mild symptoms or have experienced symptoms in the two weeks prior to your appointment. We are counting on all of our clients to uphold this guideline.

3. Please Wash Your Hands Upon Arrival. We will be sanitizing door handles and treatment rooms between clients but washing your hands will help keep risk of exposure to a minimum.

5. Please No Additional Guests. Only those scheduled for massage should enter the office. Close contact services are already considered to be high risk so allowing additional guests at this time is just not responsible practice.

In undertaking a massage with Deep Tissue Boise, I agree to the following:

I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from Deep Tissue Boise and my therapist.

In the spirit of understanding, I agree to hold Deep Tissue Boise, Idaho Wellness Group, and my therapist blameless for any problem that might arise as a result of my massage sessions.

I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.

I have Read and Agree to all of the above Covid-19 Policies and Consent:*

Signature *

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Health History

Narrowing Your Treatment Plan

The following are massage caveats we want to avoid. Tell your therapist if you are experiencing any of the caveats listed below.

Please check when true during any previous massage.

Below are common styles that can emerge in a typical massage session.

Check any style of depth that describes your desired experience.

It is our goal to empower you to understand the basics of your body. Knowing your body will help you communicate with your therapist in order to facilitate the best results.

Please view the following image to determine (to the best of your ability) which muscles or areas are the reason for your visit.

INFORMED CONSENT & COVID RELEASE OF LIABILITY

In undertaking a massage with Deep Tissue Boise, I agree to the following:

COVID-19 INFORMED CONSENT & MANDATORY POLICIES