Aberdeen Massage Intake Form

701 N 4th street Suite 1, Aberdeen, SD 57401

605-377-5930 | www.aberdeen-massage.com | aberdeensdmassage@icloud.com
New Client Intake Form
Name*

First NameLast Name
Gender*
Current Age*
Phone Number*

Area CodePhone Number
Email*
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
How do you prefer for Aberdeen Massage to contact you? *
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about me?*

FacebookInstagramGoogle SearchRadioReferral (type name below)Other
What is your occupation? *
Would you prefer a male or female therapist*

Female onlyFemale preferredNo preferenceMale preferredMale onlyOther
Do you prefer to see Kiley Connor LMT or Russell Kimball LMT

Kiley Connor LMTHolly Novstrup LMTRussell Kimball LMT
How often do you like to get a massage/bodywork?
When was your last massage or bodywork?
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
In your entire lifetime, 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 RemovalI have not had any of these SurgeriesOther
Please list any surgeries not listed above:
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 an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
If you are pregnant, when is your due date ?
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
Do you have any known allergies that require an epi-pen?*

YesNo
Please note that if you have an allergy that requires an epi-pen. Aberdeen Massage does not have epi-pens available, it is your responsibility to have said epi-pen on your person.
Please list any allergies that require an epi-pen
Please list any other allergies
Do you have any special needs I should prepare for?
Do you have a favorite body part to have worked on ?

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

Medical History*

	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
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

Informed Consent
Special Consent for Massage of Inner Thighs and Gluteal Muscles (Buttocks)

What are these areas?
- Inner thighs: adductor muscles
- Gluteal ( Buttocks) : gluteal muscles, piriformis, upper and lateral sacrum, 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 and inner thigh.

Client Education = Empowerment

In order to achieve treatment goals, your therapist may deem it neccessary to work on muscle or connective tissue in the inner thighs and buttocks

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. Communication is very important and our goal is to take care you, as such we would never want you to feel uncomfortable.

Please let your therapist know immediately if at any time treatment feels uncomfortable in any way.
Consent for Massage of Inner Thighs and Gluteals*
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, your therapist may deem it appropriate to work on muscle or connective tissue near or underneath breast/chest tissue. Your therapist will do their best to avoid breast tissue and minimize pressure.

Even if you consent to chest region massage today you can choose not to receive it at any point of your treatment or limit the massage. You, the client, have the right to change consent at any time during a treatment. Communication is very important and our goal is to take care you,as such we would never want you to feel uncomfortable. .Please let your therapist know immediately if at any time treatment feels uncomfortable in any way.
Consent for Massage of Chest Region*
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.
- Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 100% of the scheduled appointment fee. Payment is due immediatly.
Fragrance-Free Policy

Aberdeen Massage asks for all clients to refrain from wearing perfume, cologne, after-shave, scented lotions, body sprays or other similar "smelly" products on the day you visit Aberdeen Massage.

Synthetic chemicals found in scented products can trigger migraines and asthma attacks in our sensitive clients.
Smoke-Free Policy

Smokers are asked to please shower before your appointment and avoid smoking until after your appointment; this helps us avoid the smell of smoke in our office, which triggers migraines and asthma attacks in our most sensitive clients, especially children.
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?
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 Aberdeen Massage in its entirety.

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

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

4. I have read and I understand the Etiquette & Policies for Aberdeen Massage and I agree to the terms and conditions outlined in the Etiquette & Policies.
Type Full Name:*

First NameLast Name
Signature*
Today's Date*

MonthDayYear
Newsletter

Yes, I'd like to subscribe to Aberdeen Massage's mailing list for special events and last-minute openings.
Newsletter

Yes, subscribe me to this newsletter.
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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 Aberdeen Massage in its entirety.

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

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