Client Health History / Intake Form-Mysite

Client Health History / Intake Form

Energy in Motion Massage ------ Angie Simmons, CMT & Amy Simmons, CMT The following information will be used to help plan safe and effective massage sessions and is, of course, confidential. Please answer the questions to the best of your knowledge. Draping will be used during the session – only the area being worked on will be uncovered. If you are uncomfortable with the draping at any time, it is your responsibility to communicate that with me, so that I can adjust the draping. I will do everything within my power to create a session for you that feels safe, comfortable, and nurturing. (This is a google document, so you are unable to sign in this format. A copy of this document, filled in with your responses, will be provided for you to sign at your first session.)

Last Name

First Name

Email Address

Cell Phone Number

Date of Birth

What are your preferred pronouns

Occupation

Name of your emergency contact (first and last name)

Phone number for your emergency contact

Date of initial visit

Have you had a professional massage before? If yes, how often do you receive massage therapy?

Do you have any difficulty lying on your front, back, or side? If yes, please explain.

Do you have any allergies to oils, lotions, or ointments? If yes, please explain.

Do you sit for long hours at a workstation, computer, or driving? OR do you perform and repetitive movements for work or hobbies? If yes, please describe.

Do you experience stress in your work, family, or other aspect of your life? If yes, how do you think it has affected your health? (Muscle tension, anxiety, insomnia irritability other, etc).

Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? If yes, please identify.

Do you have any particular goals in mind for this massage session? If yes, please explain.

Are you currently under medical supervision? If yes, please explain.

Are you currently taking any medication or OTC drugs? If yes, please list.

Please explain any condition(s) that you marked above.

Is there anything else about your health history that you think would be useful for your practitioner to know to plan a safe and effective massage session for you?

How did you find our services?

Google

Facebook

AMTA Website

Personal Referral

If you were personally referred by a person or business, please tell us who so we can thank them!

I understand that the massage I receive is provided for the purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform Angie so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage is not to be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

Your Signature