Muscle Maintenance Massage Client Intake Form

Muscle Maintenance Massage

19 Brighton Place, EH15 1LH

07846710150 | musclemaintenanceportobello@gmail.com | www.musclemaintenancemassage.co.uk
Client Intake Form
Name*

First NameLast Name
Phone Number*
Email*
Your Birthday*

DayMonthYear
Address

Street Address

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City

Post Code
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
GP Name and Address

Name

Street Address

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Postal / Zip Code
How did you hear about Muscle Maintenance Massage?

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Have you visited Muscle Maintenance Massage before?*
Please state your reason for booking the massage treatment today.
What sport or exercise do you normally do?
Please list any significant HEAD INJURIES; concussions, being knocked unconscious, or traumatic brain injuries.
Please list any significant INJURIES including head injuries or traumatic injuries to your joints, muscles, or bones.
Please list any SURGERIES you have had in your lifetime.
Are you currently seeing any other healthcare professionals or awating any tests, surgery or investigations?
Do you have an implanted electronic device in your body (Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
Are you currently taking any MEDICATION?*
If yes, please give details:
Do you have any ALLERGIES? (Please include all allergies - food, medicine, animals etc)*
If yes, please give details:
General Medical History: If you have experienced any symptoms marked with an asterisk (*), the therapist may call you to discuss your medical history before attending your appointment; this is to ensure your safety and well-being and to confirm it is safe for you to receive the treatment.

Medical History (please select all that apply)*

	Current	Past
Pregnancy*
Blood Clots*
Congestive Heart Failure*
Thrombosis or Unexplained Calf Pain*
Stroke or Heart Attack*
Cancer
High Blood Pressure
Low Blood Pressure
Epilepsy / Seizures
Chronic Headaches / Migraines
Chronic Dizziness / Ringing Ears
Digestive Disease (IBS, Crohns, etc)
Kidney Disease / Chronic UTI's
Arthritis (rheumatoid, osteoarthritis)
Scoliosis / Kyphosis / Lordosis
Osteoporosis
Degenerative Spine / Disk
Autoimmune Condition (Coeliac, Hashimotos, Lupus, Graves, etc)
Diabetes / Insulin Resistance
Endocrine / Thyroid Condition
Depression
Anxiety
Asthma
Chronic Pain
Chronic Numbness / Tingling
Neurological Condition (ALS, Parkinsons, etc)
Fibromyalgia
Multiple Sclerosis
Memory Loss / Confusion
Varicose Veins
Haemophilia
Skin Disorders
Untreated HIV/AIDS
Hepatitus
Phlebitis
Oedema
Cellulitis
Sciatica or Nerve Impingement
Sinusitis
Repetitive Strain injury
NONE OF THE ABOVE

Do you have any other medical conditions or is there anything else of relevance you would like us to be aware of?
If attending for Manual Lymphatic Drainage, please be aware that it is not recommended for those suffering from heart conditions, kidney problems, cellulitis, venous thrombosis or an active infection. Do you currently have any of the above?
If you have answered yes, please provide details:

Massage Therapy Policies
- Please aim to arrive 5 minutes before your appointment.
- A pre-treatment consultation will be had to determine what you would like to achieve from the session and to discuss any muscle complaints or problematic areas requiring more attention.
- Please turn off your mobile phone for the duration of your treatment.
- Face masks are no longer a requirement but you are welcome to wear one yourself or request that your therapist wears one if it would make you feel more comfortable.
- The treatment room and couch will be cleaned and sanitised between appointments.
- The massage therapist or client can end the session at any time for any reason.
- If you feel pain or discomfort at any point during your massage, please inform your therapist so that techniques or pressure can be adjusted to your comfort level.
- Your modesty is protected at all times. You will be draped and at no point will genitalia or breast tissue be exposed.
- Inaproppriate behaviour will not be tolerated and may be prosecuted to the full extent of the law. The treatment session will be ended if the client engages in any inappropriate behaviour including but not limited to illicit or sexually suggestive remarks, sexual advances, drug use, excessive drinking and/or other inapporopriate behaviour.
- All client consultation forms and personal client data will be held securely in compliance with all applicable data protection laws. We will not share your information with anyone else. Please see our Privacy Policy or contact us via email for more information.
- If payment has not been made at the time of booking, either cash or card payment can be accepted at your appointment.
Cancellation Policies
- 48 hours notice is required when cancelling an appointment otherwise this will be counted as a ‘missed session’. You will be charged 90% of the service fee, 'no-shows' will be charged 100%. To cancel or ammend a booking please email musclemaintenanceportobello@gmail.com or call/message us on the number provided above.
- Late arrival: If you arrive late, your treatment may be shortened to accommodate subsequent bookings. Upon late arrival, you will be responsible for payment of the full service scheduled. Please aim to arrive 5 minutes before your treatment.
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 the following symptoms, you will kindly be asked to reschedule your treatment.

Fever or chills
Vomiting or diarrhea
Contagious skin disorders
Sore throat or cough
Other symptoms of covid or influenza (flu)
We would love to send you exclusive offers, discounts and occasional news about what's happening with Muscle Maintenance. Are you happy for us to add you to our mailing list?*
**We will always treat your details with care and never sell them to third parties for marketing purposes.
Client Agreement
1. I give my permission to recieve massage therapy.
2. I understand that it is my responsibility to inform my massage therapist of any discomfort during the treatment so they can adjust accordingly.
3. I understand the importance of informing my massage therapist of all my medical conditions and medications I am taking. I have stated all my known health issues and will keep my therapist informed of any changes to this.
4. I understand that massage therapists do not diagnose illnesses or injuries or prescribe medication.
5. I understand that massage therapy is not a substitute for medical treatment. I will seek medical advise from my GP should the situation with my health change.
6. I understand that the massage therapist or client may terminate the treatment at any time.
7. I understand the risks associated with massage therapy include, but are not limited to:
  • Superficial bruising
  • Short-term muscle soreness
  • Exacerbation of undiscovered injury
  I therefore release Muscle Maintenance and the individual massage therapist from all liability concerning any harm that may unintentionally occur during or as a result of the massage session.
8. I have read the Client Intake Form for Muscle Maintenance in it's entirety. I fully understand all questions and have answered them accurately and to the best of my knowledge.
9. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken.
10. By signing this form I agree to the conditions as outlined above.
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