Simplicity Massage Therapy
Life is complex, experience an hour of simplicity

New Client Intake Form

 

 

 

Name__________________________________________________________________        

Address_________________________________________________________________

City____________________________       State_______        Zip__________________

Cell Phone ______________________________________________________________

Work ______________________________________________Ext__________________

Home Phone_____________________________________________________________                                                                                    

Date of Birth ________________________         Male ________         Female_________

Height________________     Weight ______________        Age____________________

Emergency Contact________________________________________________________

Phone___________________________________________________________________

Email ___________________________________________________________________

Occupation ______________________________________________________________

May we contact you by email with specials and promotions?   Y/ N.

Appointment reminders are sent 2 days prior by email,1 day prior by text is this acceptable? Y/N.

Pressure Preferred Mild _________      Moderate________      Firm________

Desired results, Relaxation __________ Pain Relief_________ Increased Flexibility_______­­__

Had massage before Y / N. last Date________________________

What kind of exercise/sports do you do

____________________________________________________________________________________

Describe any recent injuries, illnesses, broken bones, or surgical operations in the last two years .

________________________________________________________________________

Are you taking any medications for a heart condition or for pain management, if so what?

________________________________________________________________________

Please check (X) any of the conditions below that apply to you.

HEAD_____ TMJ          _____ Grind Teeth

_____Head feels heavy    _____Lights bother eyes

_____Ringing in ears R___ L ___

_____Loss of balance    _____Headaches/

where___________________________________________________________________

NECK / SHOULDERS

_____Stiff neck _____Pain in neck with movement

_____Can’t raise arms above shoulder

_____Can’t raise arms over head

HANDS

_____Hands are cold        _____Loss of grip

_____Shooting pain in arm /hands

LOW BACK

Low back pain when, Lifting ____ Sitting _____

_____Lying down _____ Bending _____

_____Coughing _____ Getting up _____

_____Sciatica R ___ L ___

HIPS/LEGS/FEET

_____Leg or foot cramps     _____Cold feet

_____Swollen ankles      _____Ticklish feet

_____Varicose Veins R ___ L ___

_____Hip replacement R ___ L ___

_____Knee replacement R ___ L ___

____Knee(arthroscopic) surgery R ___ L ___

FEMALE

_____Pregnant , # Months _____

_____Post partum depression

_____Menstrual pain      _____Irregular cycle

GUT

_____Nausea   _____Gas    _____Diarrhea

_____Constipation

OTHER

Allergies/ Type/medications

________________________________________________________________________

Bursitis / where ___________________________________________________________

Arthritis/Type/Where_______________________________________________________

Blood pressure high __________ low _________

Bruise easily _______         Sinus_______

_______Osteoporosis _______Shortness of breath

Seizures, convulsions, epilepsy/explain__________________________________________

Cardiac/circulatory condition/explain____________________________________________

Stroke or closed head injury/ explain____________________________________________

_________________________________________________________________________

Diabetes Type 1 / 2 Insulin dependant  Y/N

Infectious Disease/condition/explain ____________________________________________

_________________________________________________________________________

Inflammation/ where ________________________________________________________

Skin condition/ rash/ where/___________________________________________________

Strain/Sprain/ Date/Where ____________________________________________________

Other______________________________________________________________________

 

Suggestions for getting the most benefit from your massage

If you notice yourself holding your breath, release the air from your lungs. Exhaling releases tension, holding your breath retains tension.

     Exhale when your Therapist is applying pressure or stretching a muscle.

     Communicate with your Therapist

     Drink more water than you normally would in the 24 hours following your massage.

 

I understand that the massage/bodywork I receive from the massage therapist is provided for the basic purpose of relaxation and relief of muscular tension. I further understand that massage/bodywork should not be considered as a substitute for a medical examination, diagnosis, or treatment. I also understand that the massage therapist does not diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the sessions(s) given should be considered as such.

 

               Because massage/bodywork is contraindicated (should not be performed) under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions on this form and/or asked by my therapist, honestly and completely to the best of my knowledge. If I have specific medical conditions or symptoms where massage/bodywork is contraindicated, I agree to keep my massage therapist updated in future sessions as to any changes in my medical profile. I also agree there is no liability on the massage therapist part should I fail to do so.

 

               If I experience any pain or discomfort, during this session, I will immediately inform the therapist so their pressure, strokes, and or technique may be adjusted to my comfort level. If at any time I should feel uncomfortable with any part of the massage or the area being massaged or any other concern, I am to inform the Therapist immediately.

               

               Any illicit or sexually suggestive behavior either physical or verbal made by me, will result in immediate termination of the session and I will be liable for the “full” scheduled appointment and that I may be reported to the appropriate authorities.      

Clients Initials ___________

 Client Signature________________________________    Date ____________

 Therapist Signature _______________________________

Associated Bodywork & Massage Professionals
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