New Client Intake Form

Please complete and submit the following form before your appointment date otherwise,
you will be required to complete the form onsite before your session.

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First Name           Last Name
 Email Address:
Street Address City
State Zip Code
Home Phone: Work Phone: EXT.
Cell Phone: Preferred Method of Contact:
Have you ever had a professional massage? Yes No

If yes, how often?
Type of massage requesting
What are your goals for treatment?

Areas to be worked
(If you have a focused or half session please only select the few specific areas that are to be treated)
Please note: Most 60 minute sessions include work on the areas followed by a *.  If you wish to have work done on an area that does not have a star by it, you will either need to upgrade to a longer session, not select one of the starred options below or understand less work will be spent on other areas to include the additional treatment area(s). 
90 minute sessions may select all of the areas below.

I give the massage therapist my permission to work on the following areas of my body:

Focused Session                                                                          

 

Front of Legs*

Scalp

 

Upper Thighs*

Face

 

Back of legs*

Neck/Shoulders/Chest *
(upper area of chest for women/pectoral area included for men)

 

Outer Thighs*

Arms*

 

Feet*

Hands*

 

Gluteus Muscles*

Abdomen

 

Back*

IMPORTANT:
Please enter the areas from above that you did NOT check and therefore want to be avoided.
What are your common areas of pain, tension or stress where you would like more focused work on?
Any minor injured/cut or bruised areas to work around or avoid Yes No

Medical  History and Information
  Requesting the below medical information is not meant to be an invasion of your privacy; it is simply that with some conditions, massage therapy is not right for you. Protecting your health and safety is my primary goal.

 Check any or all the apply to your present health

Pregnant                                          

 

Low Blood Pressure                         

 

Cancer

Headaches/Migraines

  

Hip/Back Pain

  

Rashes

Allergies

  

Sprains/Strains

  

Digestive Disorders

Contacts

  

Spasms/Cramps

  

Scoliosis

Sensitive skin

 

Arthritis/Joint Pain

 

Blood Clots

Sleep difficulties

 

Chronic pain

  

Fibromyalia

Sinus problems

 

Varicose Veins

  

Heart Attack

Bruising

 

  High Blood Pressure

 

Kidney Problems

Contagious Conditions

 

Osteoporosis

 

Heart Condition

Fatigue

 

Carpal Tunnel Syndrome

 

Epilepsy

Swelling

 

Depression

 

Constipation

Skin Disorders

 

Numbness

 

TMJ

Diabetes

 

Dizziness

 

Other (see below)

For your protection, if you have any of the conditions listed below,
I ask that you please supply a letter of clearance from your physician to receive massage treatment.

Autoimmune disorders

 

Multiple sclerosis (during acute stage)

 

Sickle cell disease (in acute phase)

Hepatitis

 

Infectious conditions:
including ringworm, scabies,
infectious diarrhea, the flu, etc.

 

Recent major injury and/or surgery
(if you want area worked)

Contact dermatitis

 

Lupus (during acute stage)

 

Scleroderma (in acute phase)

Fever

 

Gallstones (during acute stage)

 

Pericarditis

Do you have any other current health condition(s) that would limit your ability to receive massage
or need any special accommodations?   Yes No

If yes, please explain
 
Sensitive to fragrances, perfumes or specific lotion ingredients? Yes No

If yes, please list them
 
Recent injuries/surgeries: Yes No

If yes, please describe
 
 What other treatments are you receiving? (acupuncture, physical therapy, chiropractic, naturopathic):
How did you hear about RelaxAmerica Massage?       Referred by
 

Relax, you’re in good hands!




Informed Consent and Massage Policies

I understand that the massage I will be receiving from RelaxAmerica Massage is for the purpose of stress reduction, relief from muscular tension or spasm.  I understand that the massage therapist does not diagnose illness, disease, or any further physical or mental disorders.  As such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform spinal manipulations.  I understand that massage is not a substitute for medical treatment or diagnoses and that it is recommended that I see a physician for any physical ailments that I may have. 

I acknowledge that the information I have provided on this form is correct and current to the best of my knowledge. I understand that it is my responsibility to inform the massage therapist of any changes to this information.  I understand that if I experience any unusual discomfort and/or pain during my massage sessions it is my responsibility to inform the massage therapist so that they can adjust the pressure or technique being used.

Privacy Policy- All written records and massage sessions are kept strictly confidential and will not be shared with any outside establishment, individuals, organizations, or medical facilities without explicit written consent from the client (you) or the client’s legal guardian.  Unless legally required by local, state, or federal subpoena, summons, or other court order.

By completing and submitting this form, I confirm my consent to treatment.

Please type your name in the consent box:

In office use:    Client Signature ______________________________________