Massage Therapy Client Intake

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.
Full Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number
This is my:
E-mail
Emergency Contact
Phone Number
Occupation
Medications
Allergies
History of Pathology
1. List Areas of Discomfort or Pain
2. Describe Onset of Discomfort or Pain
3. Rate of Pain Today
4. Frequency - please select the most accurate

ConstantOff/OnAt RestWith ActivityOther
5. At what time of day is the pain at its worse?

MorningAfternoonEveningDuring SleepOther
6. Have you ever injured this area before?
7. Have you ever been in an accident (automobile, work, falls, etc.) ?
8. List all related treatments received for this injury.
9. Have you ever received therapeutic massage for a specific problem or injury?
Was the treatment used effective?
10. Is there anything that you do that creates, increases or decreases pain?
11. What are the physical duties required of your occupation?
12. What activities/hobbies do you enjoy?
13. Please list exercise and stress reduction activities (including frequency).
14. In what position do you most often wake up?

BackSideStomachOther
15. Are you currently seeing any other healthcare professional?
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
Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off your cell phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 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

       • You will have a consultation with your therapist to discuss your session

       • Should the session require, after your therapist has left the room, you may disrobe to your comfort level

       • 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 Octarine Therapies, the location site of the treatment, and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

Therapeutic Treatment Release Form:

Liability Waiver for all Treatments

Offered by:

Octarine Reiki Meditation Center Arizona

Or OctaReiki or Octarine Therapies

Legal business name:

Miaura Checchia LLC

This document is set forth to release the risks involved, including potential injuries or discomfort during the treatment, and state that the participant releases the provider from any liability for such occurrences. The participant assumes responsibility for any injuries or harm that may have occurred before the treatment, during the treatment, or what follows the treatment.

1. Release Clause:

This is a release clause that states the participant releases the Therapeutic Treatment provider from any liability for injuries or harm that may occur during the treatment. The participant will not hold the provider liable for any claims, damages, or losses.

2. Assumption of Risk:

This waiver explicitly states that the participant assumes all risks and responsibility for any injuries or harm that may occur during the treatment. This clarifies that the participant understands and accepts the potential risks associated from receiving Therapeutic Treatments.

3. Disclaimer:

This waiver is a disclaimer stating that a Therapeutic Treatment is not a substitute for medical treatment or diagnosis. The provider is not a medical professional and cannot diagnose or treat medical conditions. We do not make any claim to offer cures or treatment of any disease or illness. If you are sick, please consult with your doctor or health care practitioner.

4. Acknowledgment: By signing below, you acknowledge that you have read and

understand this document, and have received acceptable answers to all of your questions and consent to receiving a Therapeutic Treatment. You hereby agree to release the provider for any liability or damage that may incur due to the Therapeutic Treatment.

I, the undersigned, consent to a Therapeutic Treatment. I understand that

these procedures are for the purpose of detoxification and are not intended to take the place of medical care or medications. I clearly confirm that I do not have any contraindications to receiving a Therapeutic Treatment. I understand that I can discontinue my treatments at any time. I understand that I take full responsibility for my own health and well-being and agree to keep my account settled after every treatment.

By my electronic signature below, I agree to the massage policy, therapeutic treatment release form, and client agreement above.
Signature*

Powered by Jotform SignClear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty: