Massage Therapy Client Intake Form

BWFT Client Intake Form

All information is held in the strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name

First NameMiddle NameLast Name
Date

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Birth Date

DayMonthYear
E-mail
example@example.com
Phone Number
Format: 00000000000.
This is my:
Emergency Contact

First NameLast Name
Phone Number
Format: 00000000000.
Your Occupation
Medications
Allergies
History of Pathology
1. List Areas of Discomfort or Pain
2. Describe Onset of Discomfort or Pain
3. Rate of Pain Today
4. Frequency - please select the most accurate

Other
5. At what time of day is the pain at its worse?

Other
6. Have you ever injured this area before?
7. Have you ever been in an accident (automobile, work, falls, etc.) ?
8. List all related treatments received for this injury.
9. Have you ever received therapeutic massage for a specific problem or injury?
Was the treatment used effective?
10. Is there anything that you do that creates, increases or decreases pain?
11. What are the physical duties required of your occupation?
12. What activities/hobbies do you enjoy?
13. Please list exercise and stress reduction activities (including frequency).
14. In what position do you most often wake up?

Other
15. Are you currently seeing any other healthcare professional?
16. Recent Medical History
Are you or have you recently been pregnant?
Within the last 5 years have you suffered with or being diagnosed with any of the following health conditions?

Other
17. Areas you would prefer to avoid:
18. What kind of pressure do you like?
19. What treatment are you recieving today?

Other
20. Please check any symptoms that apply to you and indicate right or left when applicable:
Head

Other
Neck

Other
Shoulders

Other
Arms & Hands

Other
Low Back

Other
Mid-Back

Other
Hip

Other
Legs and Feet

Other
21. We may ask whether we can take pictures/video's during your session to use for our social media, website and marketing. Do you consent to having your photo/video being taken and shared on our social media, website and marketing?
Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off your mobile phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged for your session

       • You will be draped and at no time will genitalia or breast tissue be exposed

       • You will have a consultation with your therapist to discuss your session

       • Should the session require, after your therapist has left the room, you may disrobe to your comfort level

       • I understand that my therapeutic massage therapist or I may end the session at any time for any reason

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement:

I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic massage as a form of therapy.

I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Therapy Center and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
Date

MonthDayYear
Date
Signature

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

BWFT - Informed Consent

To be completed before therapy.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: 00000000000.
MASSAGE READINESS QUESTIONNAIRE for SPORTS MASSAGE THERAPY TREATMENT

INFORMED CONSENT FOR SPORTS MASSAGE THERAPY TREATMENT

I understand that the sports massage therapist is providing sports massage therapy services within their scope of practice as defined by the Massage Therapy Association.

I hereby consent for my therapist to treat me with sports massage therapy for the above noted purposes including such assessments, examinations, and techniques, which may be recommended, by my therapist.

I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my general practitioner for any symptoms 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. I have completed my medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to keep the massage therapist updated on my medical history.

The information I have provided is true and complete to the best of my knowledge.
I authorise my therapist to release or obtain information pertaining to my condition(s) and/or treatment to/from my other caregivers or third-party payers.

I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical
condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
Date

DayMonthYear
Date
Signature
Should be Empty:

BWFT Client Intake Form

History of Pathology

BWFT - Informed Consent