HCS Offshoots Massage Intake

Client Name (HCS Patient)

First NameLast Name

Chosen Pronouns

He/HimShe/HerThey/ThemOther

Client E-mail*

Contact phone number (to arrange and confirm the appointment).

Please enter a valid phone number.

Primary Care Giver Name

First NameLast Name

Primary Care Giver E-mail*

example@example.com

Primary Care Giver's Phone (if different than the contact phone number given)

Please enter a valid phone number.

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please describe the residence location where the massage is to occur to help us get there and plan ahead. For example, what color of is the building? Are there any special directions to get to the right entranceway?

CLient Health History

Client Birth Date*

MonthDayYear

Please list any medications that you are currently taking & the conditions they are treating.

Please tell us about any allergies or hypersensitivities.

Have you had a professional massage before?*

YesNo

Do you suffer from seizure disorders or epilepsy?*

YesNo

Have you ever been treated for cancer?*

NoYes

Did your cancer treatment include any of the following?*

SurgeryChemotherapyRadiation

Did your cancer treatment include any of the removal or radiation of lymph nodes.

NoYesNot sure

Do you have any pins, plates or artificial joints?*

YesNo

Have you ever been diagnosed with a blood clot?*

NoYesNot sure

Do you have numbness or stabbing pains anywhere?*

YesNo

Where?

Are you very sensitive to touch / pressure in any area?*

YesNo

Where?

Have you had any surgeries or injuries in the past 2 years that may influence your massage treatment?*

YesNoNot sure

Please explain.

Please check any conditions that apply to you.*

Do you have any other medical condition that you think that your massage therapist should be aware of?*

YesNo

Please explain.

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.

I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so.

I consent to Home Healthcare Hospice and Community Service to share medical and other information relevant to massage therapy with Deep Roots Massage & Bodywork, LLC.

I understand that massage may be contraindicated for specific medical conditions or specific symptoms.

I understand that the massage that I receive is provided for the basic purpose of relaxation. If I experience any pain or discomfort during this session I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

I understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should consult a physician or other qualified medical specialist for any mental or physical ailment that I am aware of.

I understand that massage/bodywork therapists are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

Client Signature*

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

HCS / Deep Roots Offshoots - Massage Therapy Application & Client Intake