Full Body Focus: Client Intake Form (Massage)

FULL BODY FOCUS

8 Fromont Drive, Thatcham, West Berkshire RG19 3PE

07876661777 | www.fullbodyfocus.com | fullbodyfocus@outlook.com
New Client Intake Form

Massage Therapies
Name*

First NameLast Name
Gender*
Phone Number*
Email*
Your Birthday*

DayMonth Year
Address

Street Address

Street Address Line 2

Town/CityCounty

Postcode
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
How did you hear about me?*

FacebookInstagramGoogle SearchReferral/RecommendationOther (please specify)
Type a question
How often do you like to get a massage/bodywork?*
When was your last massage or bodywork?*
What would you prefer during your massage session? *
Do you have any aims/motivations for having this treatment? If yes, please explain your desired outcome.
If left blank it will be submitted as a 'No'.
What are your top priorities to be addressed at your appointment?*

Lower Back PainNeck PainHip PainTight Glutes (Butt Muscles)Shoulder IssuesTension HeadachesNothing SpecificOther
Do you have any current issues that are affecting you/your body?*
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 RemovalNONE OF THESEOther
Please list all surgeries:
BODY INJURY: Please list any significant injuries to your joints, muscles, or bones.
If left blank it will be submitted as a 'No'.
Do you have any special needs I should prepare for?
If left blank it will be submitted as a 'No'.
Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
Are you taking any prescription medications that I should be aware of?*

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

Medical History*

	Current (or within 6 months)	Past (over 6 months)	Never
Pregnancy - in the last 3 months*
Blood Clots*
Pacemaker*
Congestive Heart Failure*
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
Any infectious conditions and/or diseases*
Skin infections anywhere* Including nits, lice etc
Recent unhealed injury, operation or surgery*
Cardio-vascular conditions such as Thrombosis, Phlebitis etc

Medical History (continued)
If you have ticked 'Current' or 'Past' to any of the above (Medical History) OR have experienced other conditions you feel your therapist should know about, then please provide any relevant context here.
Do you have any questions or concerns you'd like to ask prior to your treatment? If so, please provide full details here.

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. You're encouraged to arrive 5 minutes before your appointment, but please do wait in your car/outside until a minute or two before your your booked time slot. This is because your therapist may be finishing up with another client.
50% Payment is required for the following condition:
- Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 50% of the scheduled appointment fee.

Good Hurt vs. Bad Hurt

When you get a massage, you may experience "good hurt" and "bad hurt." It is important to understand the difference between "good hurt" and "bad hurt" because "bad hurt" needs to be avoided.

"Bad hurt" is when you....
- tense up
- wince in pain
- hold your breath
- cringe
- have the feeling you are trying to "push through" the pain.
Bad Hurt will actually cause your whole body to be tense and when your body is tense, the muscle knots will not release. To have the best massage results, avoid "bad hurt" by telling your massage therapist right away, as soon as you feel the "bad hurt."

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 symptoms of an illness, you will kindly be asked to reschedule your appointment to avoid the spread of germs. This protects are most susceptible loved ones - children, the elderly, & people with suppressed immune systems, like cancer patients.

If any of the following describes you, I kindly ask that you reschedule your appointment so we can prevent the spread of bugs:
- Fever or Chills
- Vomiting or Diarrhea
- Runny Nose
- Sore Throat or Cough
- You are currently taking an antibiotic.
- You have a skin infection like ringworm or athletes foot.
- You or someone in your direct care has a cold, sinus infection, or flu bug.
- You or someone in your direct care has been diagnosed with influenza (the flu).
Even if you are cancelling your appointment within the 24-hour notice period, the cancellation fee may be waived; the onset of symptoms doesn't always have great timing, right?

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.

The anal area and the genitals will always be draped (covered) and will not be touched.

Even if you consent to massage in this area today, you can always choose not to receive it at any point of your treatment. You, the client, have the right to change consent at any time during a treatment.

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*

Behaviour Policy
I am aware massage therapy is for relaxation, therapeutic and/or treatment purposes only. I understand that there is absolutely no sexual component to massage whatsoever. Any insinuation, joke, gesture, conversation, or request otherwise will result in immediate termination of the session and refusal of any and all services in the future. For any treatment cut short for this reason, I will still be liable to pay the full-service fee.

Photos and Videos
I understand that my therapist may ask my permission to take a picture or video during my treatment(s). This may be (but not limited to) to demonstrate a comparison (i.e. before and after) shot of a muscle that responsed well to treatment, or simply for demonstation and marketing purposes.

I agree to and authorise the taking of clinical photographs and videos. I understand that these clinical photographs and videos will form part of and will be kept with my confidential medical records. I authorise the use of any pictures and videos taken to be used for marketing purposes.

However, any limitations of the use of my pictures will be stated in the question boxes provided so my therapist knows. If I wish for them to be deleted, I will confirm/consult with my allocated therapist in a polite and respectful way.

If you feel uncomfortable with agreeing to this, then don't worry as you don't have too - you can use the drop down box to agree/disagree to this.

(Note from Jessi @ FBF - Even if you provide your consent to this here, no photos or videos would be taken without your verbal consent on the day(s) aswell. Your privacy will always respected and no private or sensitive areas will ever be exposed, the same way you'll always be treated during any of my sessions. My studio will always be a safe space for all my clients and you comfort and safety is my top priority).
Consent for Photos and Videos*
Box for (optional) comments:

CONTRADICTIATIONS, RISKS AND SIDE EFFECTS
As with any procedure/treatment there are potential risks and complications associated. Massage therapy is a safe and low risk, but you must be aware of the following possible risks before proceeding. You must fully discuss any questions with your practitioner.

Common risks include mild discomfort during and after the massage, you may feel achy the day after. A massage should not be very painful, you must tell your therapist straight away if you feel pain.

Rare risks include muscle injury, joint injury, bone injury or fracture, joint dislocation, neck injury, back or spinal injury and nerve injury. YOU MUST SEEK MEDICAL ATTENTION IF YOU EXPERIENCE ANY OF THESE COMPLICATIONS.

Extremely rare risks include dislodging of deep vein thrombosis or arterial plaque which could lead to a blood clot in the lung (pulmonary embolism) or stroke respectively. Extensive massage can lead to muscle breakdown (Rhabdomyolysis) which can lead to kidney failure in extremely rare cases in vulnerable patients. ALL OF THE ABOVE WOULD REQUIRE URGENT MEDICAL ATTENTION.

To ensure you are safe to receive treatment, or your treatment is managed to ensure your safety, please review the following contradictions list before proceeding to consent/acknowledgement.

TOTAL CONTRADICTIATIONS
Treatment can’t go ahead unless the condition/injury has been diagnosed and a GP referral/approval letter can be provided BEFORE treatment (it must be addressed to FULL BODY FOCUS LTD/Jessica Cotter):

- COVID-19
- Pregnancy
- Autoimmune diseases such as (but not limited to) Graves' disease, Hashimoto’s thyroiditis, systemic lupus erythematosus (lupus), type 1 diabetes, multiple sclerosis (MS), rheumatoid arthritis.
- Cardiovascular conditions such as (but not limited to) Thrombosis, phlebitis, hypertension, hypotension, heart conditions.
- Any blood disorders
- Haemophilia
- Any conditions being treated by a medical professional i.e. GP, Physiotherapist, Osteopath, Chiropractor etc.
- Medical oedema
- Osteoporosis, Arthritis or acute Rheumatism
- Paranoia, psychosis or schizophrenia
- Epilepsy
- Recent operations (include details of these in the notes sections provided)
- Diabetes
- Asthma
- Herpes
- Central nervous disorders, cerebral palsy, multiple sclerosis, Parkinsonism, Motor neuron disease
- Bells Palsy
- Trapped, pinched or inflamed nerve (i.e. sciatica)
- Cancer
- Postural deformities
- Spastic conditions
- Kidney infections
- Whiplash
- Slipped disc
- Undiagnosed pain
- Prescribed medication to treat a condition or infection.

PARTIAL CONTRADICTIATION
Treatment CAN go ahead but will be restricted to avoid the area(s) impacted by any of the following. But this must be discussed with your therapist PRIOR to your booking/treatment date:

- Fever
- Contagious or infectious diseases/areas
- Under the influence of recreational drugs or alcohol
- Diarrheal and/or vomiting
- Skin diseases (including verruca’s and fungal infections)
- Diagnosed on undiagnosed lumps, bumps or swellings
- Localised inflammation (including swelling)
- Varicose veins
- Cuts bruises or abrasions
- Scar tissue (2 years after major surgery or 6 months after smaller operation/scar)
- Recent sunburn
- Hormonal implants
- Hematoma
- Hernia
- Recent fractures (minimum 3 months)
- Cervical spondylitis
- Gastric ulcers
- Bloating (generally speaking, or after a heavy meal)

CLIENT ACKNOWLEDGMENT:
I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks.

I acknowledge and understand that the therapist must be fully aware of my existing medical conditions (including the above contraindications). I have/will complete my medical history form as provided by my therapist and disclosed to the therapist all medical conditions affecting me prior to any of my treatments going ahead. I understand it is my responsibility to keep the massage therapist updated on my medical history.
I have read and understood the CONTRADICTIATIONS, RISKS AND SIDE EFFECTS and (choose from the drop down):*

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 Full Body Focus Ltd in its entirety.

2. I fully understand all questions and information provided in the New Client Intake Form for Full Body Focus Ltd.

3. I have completed the New Client Intake Form for Full Body Focys accurately and to the best of my knowledge.

4. I have read, understood and agree to the policies previous referred to.
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FULL BODY FOCUS

New Client Intake Form

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 Full Body Focus Ltd in its entirety.

3. I have completed the New Client Intake Form for Full Body Focys accurately and to the best of my knowledge.

4. I have read, understood and agree to the policies previous referred to.