New Massage Client Intake Form

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Name* This field is required.

First Name

Last Name

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Gender* This field is required.

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Phone Number* This field is required.

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Email* This field is required.

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Your Birthday* This field is required.

Date

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Emergency Contact* This field is required.

First Name

Last Name

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Emergency Contact Phone Number* This field is required.

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What is your current occupation?

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When was your last sports massage?* This field is required.

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Do you have a preference to the amount of pressure applied during your sports massage?

Gentle Pressure

Moderate Pressure

Full Intensity

Uncertain

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Do you have a preference to chat during your massage session?

Quiet, please

Periodic check-in

Depends On The Day

Continuous conversation

No particular choice

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What are your current issues & how are they affecting you?* This field is required.(List your top priority issue to be fixed)

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Please list any current medical conditions I need to be aware of?

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Please list all surgeries you have had (if applicable):

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Please list any significant injuries to your joints, muscles, or bones.* This field is required.

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I want to make sure this works for everyone. If you have any preferences or need adjustments, feel free to share

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Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?

Yes

No

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Are you currently pregnant?* This field is required.

Yes

No

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Which prescription medications are you currently taking?* This field is required.

I am NOT taking any prescription medications.

I just take Aspirin for my heart.

I take a blood thinner medication.

Other

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Medical History: If you have experienced any of the symptoms that is marked with an asterisk (*), please call Kelsey to discuss your medical history before booking an appointment; this is to ensure your safety and well-being.

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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
A Persistant Cough
You have a skin infection like ringworm or athletes foot.
You or someone in your direct care has a flu bug/inflenza.

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?

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Click to edit...* This field is required.

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Special Consent for Massage of Chest Region

Treatment of certain chest, neck, and back issues will be most effective when it is preceded by the relaxation of surrounding muscles, which includes the pectoralis major, pectoralis minor, and intercostal muscles in the chest region.

In order to achieve treatment goals, I may deem it appropriate to work on muscle or connective tissue near or around your breast/chest tissue. I will work to avoid breast tissue and minimize pressure.

Even if you consent to your chest area being massagad today you can choose not to receive it at any point of your treatment or limit the massage recieved. You, the client, have the right to change consent at any time during a treatment .Please let me know immediately if at any time if the treatment feels uncomfortable in any way.

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Consent for Massage of Chest Region* This field is required.

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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 region: ischial tuberosity, 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, I 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 me know immediately if at any time treatment feels uncomfortable in any way.

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Consent for Massage of Inner Thighs, Gluteals, & Pelvic Floor Region* This field is required.

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Informed Consent

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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 Sean Dunn Strength & Fitness in its entirety.

2. I fully understand all questions and information provided in the New Client Intake Form for Sean Dunn Strength & Fitness.

3. I have completed the New Client Intake Form for Sean Dunn Strength & Fitness accurately and to the best of my knowledge.

4. There is no known reason why I should not be massaged

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Type Full Name:* This field is required.

First Name

Last Name

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Signature* This field is required.

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Today's Date* This field is required.

Date