Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download New Client Intake - A Touch of Tranquility
Document related concepts
no text concepts found
Transcript
1 Massage Client Intake Form Name____________________________________ Phone _____________________________________ Address__________________________________ City/State/Zip________________________________ Email_______________________________________ Referred by______________________________ Emergency Contact___________________________________ Phone____________________________ Massage History/Session Information Have you ever received a professional massage? __Yes __No What pressure do you normally prefer for your massage? (If applicable, mark more than one). __Light __Medium __Heavy Are there any areas on which you would not like to receive massage? __Head __Face __Feet __Buttocks __Abdomen __Other Circle any areas of tension or areas on which you would like me to focus. Health History Are you currently under the care or supervision of a physician for any medical conditions? __Yes __No If yes, please specify:___________________________________________________________________ Please list purpose of any current medications:_______________________________________________ _____________________________________________________________________________________ Do you have any disorders in the following areas? __Musculoskeletal __Circulatory __Respiratory Please turn over. __Skin 2 __Nervous System __Digestive __Reproductive __Other Please specify conditions in any of the areas marked above:_______________________________________________________________________________ _____________________________________________________________________________________ Do you currently have cancer? __Yes __No Additional comments or questions:____________________________________________________________________________ _____________________________________________________________________________________ I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health. I understand that a massage therapist cannot diagnose illness, disease, or any other medical, physical, or emotional disorder; nor can they perform any spinal manipulations or other medical treatments. I am responsible for consulting a qualified physician for any physical ailments I have. I understand that a massage session is a therapeutic health aide and is non-sexual. If sexual advances are made to the massage therapist, the therapist reserves the right to terminate the session immediately. I understand that if the massage therapist starts late, she will make it up to me at the end of my session, if possible, or will reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is not penalized. If there is no client following my appointment, the therapist reserves the right to decide whether she is able to go past the scheduled end time to accommodate my full massage. I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. Client Signature______________________________________ Date_________________________ Therapist Signature___________________________________ Date_________________________
