2024 Health Intake & Consent form

History & Consent Form
First Name*
Phone Number:*
Name

First NameLast Name
D.O.B*

MonthDayYear
Email:*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation/Lifestyle:*
Sharing this information gives your therapist a glimpse at how you spend your day and what areas may be troublesome or influencing your pain/injuries.
Are you a: First Responder, Active Duty Military, or Veteran?*

YesNo
Current Medications:*
Don't worry about spelling. We get it.
Emergency Contact Name & Phone *
Primary Physician's Name & Phone
Are you currently under a physician’s care for an acute or chronic illness? If Yes, please explain:*
Are you receiving any other Treatments or Therapies (Physiotherapy, Chemotherapy etc): *
Please tick any of the following that apply to you:*

ArthritisAnxiety/DepressionCancerCirculatory ProblemsDiabetesEpilepsy or SeizuresFibromyalgiaHeadaches/MigrainesHeart ProblemsHigh/Low Blood PressureInjuryJoint ReplacementNumbnessOsteoporosisRecent ScarringRecent SurgeryTMJCurrently PregnantNone of the AboveOther
Please explain information about any above conditions:
Allergies or sensitivities:*

Peanut/TreenutBeesDairyLatexNoneOther
What exercise/activities do you undertake? How often?
Affected areas:

NeckShoulderArmBackHipLegOther
Intensity of pain at its best (1 being no pain, 10 being extreme pain)
Intensity of pain at its worst (1 being no pain, 10 being extreme pain)
Is there a specific event associated with the pain? If yes, please describe:
How did you hear about us?:

For Headache/Migraine Specific Therapy, please answer the following:
Is your headache due to a trauma or injury?

YesNo
If "Yes" Please describe the event (when, what happened, what treatments have you had)
Is your pain:

IntermittentConstant
Does anything make the pain better? Worse?

For TMJ Specific Therapy, please answer the following:
Current Symptoms:

Jaw Pain or TendernessEar PainPain Behind the EyesDifficulty chewingLocking of jawClicking or Popping of JawClenching/Grinding of TeethGlopping in the ThroatNeck/Shoulder PainHeadache
For TMJ therapy, what other treatments have you previous sought:

Mouth Guard/Night Guard/Other DevicesRelaxation/Stress ReductionStretching/Facial YogaPhysical TherapyMedicationsInjectionsOther
For TMJ Therapy, if you have had an injection, what was the date of your last injection:

Level of Jaw Discomfort

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Very Painful

Please tick any of the following which apply:

Recent Surgery/Open WoundsTrigeminal Nerve PainRecent Dental TreatmentSevere PainAltered SensationsDizzinessNauseaFaintingOther

Consent and Acknowledgements
Consent for Treatment

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I also understand that massage therapy may produce side effects such as muscle soreness, mild bruising, increased awareness of areas of pain, and light-headedness amongst other possible temporary outcomes. I will tell the therapist about any discomfort I may experience during the therapy session and understand that the therapy will be adjusted accordingly.

I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis.

I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. Only upon written consent will my medical information may be shared by the various care providers involved in my care and treatment outside of Stillwater Wellness.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.

Consent for Skincare Treatment

I understand if I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort.

I acknowledge that a facial is not a substitute for medical care, medical examination, diagnosis, or treatment and should not be construed as such. I understand that estheticians are not qualified to perform, 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 agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the esthetician's part should I fail to do so.

I have stated all medical conditions and skincare practices that I am aware of and will inform and update my esthetician of any changes in my health status or home care practices. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. Only upon written consent will my medical information may be shared by the various care providers involved in my care and treatment outside of Stillwater Wellness.
Signed*

Clear
Date:*

MonthDayYear
Policies & Procedures

Please reach out if you anticipate a late arrival. While we will do everything to accommodate you, your session may be shortened to keep on schedule while the full treatment time may be charged. Your therapy times are reserved exclusively for you. We value you as our client and ask that you respect our office scheduling policies. If you must cancel or reschedule, kindly allow for 24 hours' notice. Cancellations made with less than 24 hours' notice, including those who miss their appointments with no advance notice, are subject to a 50% fee. Please note we work by appointment only. If an appointment is missed, our therapist not only loses your business but the potential business of other clients. At our discretion, cancellation fees may be applied toward future appointments. Credit cards held will not be charged unless there is a late cancellation or no-show. Clients may choose their form of payment upon checkout.

Stillwater Wellness Center therapists are Connecticut Licensed Professionals and held to the highest standards of the American Massage Therapy Association. Massage Therapy is a profession in which the therapist applies manual techniques and may apply supplementary techniques with the intention of positively affecting the client's overall health and well-being. Licensed Massage Therapists, Thai Practitioners, and Estheticians do not diagnose or prescribe for medical conditions. Our therapists may refer you to a medical doctor for diagnosis or treatment. Our services are never intended as an alternative for proper medical attention for specific medical conditions. Please refer to a medical doctor for any specific condition which may require medical treatment.
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Date*

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Date
Additional Health/Medication Information

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History & Consent Form