The Naturalpath Massage -New Client Intake Form-

Experience the Art of Restorative Muscle Therapy

5 Barrie Bay - Winkler, MB. 1-204-312-1403
NEW CLIENT INTAKE FORM
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
Your Birthday*

MonthDayYear
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
How do you prefer to be contacted? *
Which service are you booking?*

60 min-Deep Tissue Muscle Therapy $95.90 min-Deep Tissue Muscle Therapy $120.50 min-Chi Nei Tsang Abdominal Massage $120.90 min-Sciatic Nerve Treatment $130.
How often do you like to get a treatment?*
How did you hear about me?*

FacebookInstagramGoogle SearchReferral
When was your last treatment?*
What are your top priorities to be addressed at your appointment?*

Low Back PainSciatic PainNeck PainHip PainTight Glutes (Butt Muscles)Shoulder IssuesTension HeadachesOther
What are your current issues & how are they affecting you?*
What type of pain are you currently experiencing?*

Stabbing PainElectrical Pain (Sharp Electric Shock)Burning PainAchy PainWidespread Pain & TendernessMuscle SpasmsTension PainSharp Pain, Localized, Small AreaNoneOther
How did your issue/pain begin?*

SlowlySuddenlyIt has gotten worse over time.It has improved over time.I'm not sure how it happened or how it progressed.N/A I do not have an issue or pain.Other
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 RemovalOther
Please list all surgeries:
HEAD INJURY: Please list any significant head injuries, like concussions, being knocked unconscious, or traumatic brain injury.*
BODY INJURY: Please list any significant injuries to your joints, muscles, or bones. *
Do you have any special needs I should prepare for?
Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
Which prescription medications are you currently taking?*

I am NOT taking any prescription medications.I just take Aspirin for my heart.I take a blood thinner medication.Other

Medical History*

Rows	Current	Past	Never
Pregnancy*
Blood Clots*
Pacemaker*
Congestive Heart Failure*
Unexplained Calf Pain*
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

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. Please plan to arrive 10 minutes early for your appointment.
50% Payment is required for the following condition:
- Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment with 24 hours notice will result in a charge of 50% of the scheduled appointment fee. Payment is due before your next appointment.
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.

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*
Informed Consent
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 The Natural Path Massage in its entirety.

2. I fully understand all questions and information provided in the New Client Intake Form for The Natural Path Massage.

3. I have completed the New Client Intake Form for The Natural Path Massage accurately and to the best of my knowledge.

4. I have read and I understand the Etiquette & Policies for The Natural Path Massage and I agree to the terms and conditions outlined in the Etiquette & Policies.
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Today's Date*

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Experience the Art of Restorative Muscle Therapy

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 The Natural Path Massage in its entirety.

3. I have completed the New Client Intake Form for The Natural Path Massage accurately and to the best of my knowledge.

4. I have read and I understand the Etiquette & Policies for The Natural Path Massage and I agree to the terms and conditions outlined in the Etiquette & Policies.