"Relax Massage Therapy Client Health Intake Form"

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Relaxing Note
Massage Therapy Client Health Intake Form
Patient Information
Name:__________________________________________________________________________
Address: ______________________________ City: ____________ State: _____ Zip: __________
Home Phone: ________________________ Work/Cell Phone: _____________________________
E-mail: _____________________________________ Occupation: __________________________
Date of Birth: ________________________
Emergency Contact Person: _____________________________ Phone: ______________________
Are you currently under a physicians care for an acute or chronic illness? Yes ___ No ____
If yes, please explain: _________________________________________________________
If yes, who is your health care provider: ___________________________________________
Are you currently taking any prescribed medication or dietary supplements? Yes ____ No _____
If yes, please explain: _________________________________________________________
Have you received a professional massage before? Yes _____ No _____, If so, when? __________
How did you hear about Relaxing Note? ________________________________________________
What are your goals for this session: ___________________________________________________
Please list areas of tension, stress and/or pain you wish to be addressed: ______________________
________________________________________________________________________________
Health Information
Please mark an (X) by all current conditions and (P) for all past conditions.
__ Abdominal / Digestive
__ Diabetes
__ Numbness / tingles
__ Accident
__ Fatigue
__ Pregnancy
__ Allergies
__ Fibromyalgia
__ Rash / fungus
__ Anxiety
__ Headaches / Migraines
__ Sinus problems
__ Arthritis/tendonitis
__ Hearing problems
__ Sleep difficulties
__ Asthma or lung cond.
__ Hernia
__ Spinal disorders
__ Athletes foot
__ High blood pressure
__ Sprain / Strain
__ Blood clots
__ Jaw pain / TMJ pain
__ Tension / Stress
__ Chronic pain
__ Low blood pressure
__ Vision problems
__ Circulatory / Heart cond.
__ Low back pain
__ Varicose veins
__ Constipation / Diarrhea
__ Mid back Pain
__ Whiplash
__ Depression
__ Muscle / bone injuries
__ Other
__ Decreased range of motion
__ Neck Pain
Elaborate on noted areas above: ______________________________________________________
________________________________________________________________________________
Please list any recent injuries or surgeries within the past 5 years: ____________________________
________________________________________________________________________________
Please list your stress-reduction activities, hobbies, exercise and/or sport participation: ___________
________________________________________________________________________________
________________________________________________________________________________
Relaxing Note
Massage Therapy Client Health Intake Form
Patient Information
Name:__________________________________________________________________________
Address: ______________________________ City: ____________ State: _____ Zip: __________
Home Phone: ________________________ Work/Cell Phone: _____________________________
E-mail: _____________________________________ Occupation: __________________________
Date of Birth: ________________________
Emergency Contact Person: _____________________________ Phone: ______________________
Are you currently under a physicians care for an acute or chronic illness? Yes ___ No ____
If yes, please explain: _________________________________________________________
If yes, who is your health care provider: ___________________________________________
Are you currently taking any prescribed medication or dietary supplements? Yes ____ No _____
If yes, please explain: _________________________________________________________
Have you received a professional massage before? Yes _____ No _____, If so, when? __________
How did you hear about Relaxing Note? ________________________________________________
What are your goals for this session: ___________________________________________________
Please list areas of tension, stress and/or pain you wish to be addressed: ______________________
________________________________________________________________________________
Health Information
Please mark an (X) by all current conditions and (P) for all past conditions.
__ Abdominal / Digestive
__ Diabetes
__ Numbness / tingles
__ Accident
__ Fatigue
__ Pregnancy
__ Allergies
__ Fibromyalgia
__ Rash / fungus
__ Anxiety
__ Headaches / Migraines
__ Sinus problems
__ Arthritis/tendonitis
__ Hearing problems
__ Sleep difficulties
__ Asthma or lung cond.
__ Hernia
__ Spinal disorders
__ Athletes foot
__ High blood pressure
__ Sprain / Strain
__ Blood clots
__ Jaw pain / TMJ pain
__ Tension / Stress
__ Chronic pain
__ Low blood pressure
__ Vision problems
__ Circulatory / Heart cond.
__ Low back pain
__ Varicose veins
__ Constipation / Diarrhea
__ Mid back Pain
__ Whiplash
__ Depression
__ Muscle / bone injuries
__ Other
__ Decreased range of motion
__ Neck Pain
Elaborate on noted areas above: ______________________________________________________
________________________________________________________________________________
Please list any recent injuries or surgeries within the past 5 years: ____________________________
________________________________________________________________________________
Please list your stress-reduction activities, hobbies, exercise and/or sport participation: ___________
________________________________________________________________________________
________________________________________________________________________________
Please use the letters provided in the key to identify the symptoms
you are feeling today. Circle the area around each letter,
representing the size and shape of each symptom location.
Notes: _______________
P = pain or tenderness
_____________________
S = joint or muscle stiffness
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N = numbness or tingling
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
____________________________________________________________
Referral System:
Many of you have helped our practice grow by recommending Relaxing Note to your friends, family, and co-workers. To
thank you in return, when someone puts your name in the “How did you hear about us” line of this health form, we will send
you a $20.00 coupon towards your next visit.
Hot Tub Disclosure:
The use of a hot tub (spa), carries risks that may result in serious injury or death. Elderly persons, expecting mothers,
menstruating females and anyone subject to heart disease, diabetes, low or high blood pressure, strokes, epilepsy, or similar
medical issues should not enter a spa alone and without consulting their physician first. Never use a spa while under the
influence of drugs or alcohol. If you are taking medication of any kind, or being treated for any illness, consult your physician
prior to use of the hot tub (spa). THE UNDERSIGNED hereby ASSUMES FULL RESPONSIBILITY FOR RISK OF BODILY
INJURY, DEATH OR PROPERTY DAMAGE due to the negligence of the releases or otherwise while in the spa/hot tub.
Cancellation Policy:
Your appointment time has been specifically reserved for you. A 24 hour notice is required for schedule changes or
cancellations. There is a $25 fee added to your session for changes or cancellations made with less than 24 hour notice.
I am responsible for paying for any appointment cancellation of less than 24 hours. _______ (initials)
I understand that Relaxing Note L.L.C. abides by the H.I.P.A.A. regulations, and that all my records and information is
confidential. _________ (initials)
I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. I
will inform my health care provider and massage therapist if anything changes in my status. I understand that massage/
bodywork I receive is for the purpose of stress reduction and the relief form muscular tension, spasm or pain and to increase
circulation. If I experience any pain or discomfort, I will immediately inform my massage therapist so that the pressure and/or
methods can be adjusted to my comfort level. I understand that my massage therapist does not diagnose illness or disease,
nor perform any spinal manipulations, and does not prescribe any medications/treatments. I acknowledge that massage is
not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services. If I
am unable to attend my scheduled appointment, I will respect and abide by the set cancellation policies. Sexual advances,
requests for sexual favors and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and
will not be tolerated. I understand that I am receiving massage therapy at my own risk. In the event that I become injured
either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy I hereby hold harmless and
indemnify the therapist, their principals, and agents from all claims and liability whatsoever.
Client Signature: _______________________________________________ Date: ______________
(Relaxing Note Use:)
Photo ID Checked:
No. ______________________
Witness: _________________________
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