Massage Therapy Client Intake

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Full Name *

First Name Last Name

Date *

Month Day Year

Address *

Street Address

Street Address Line 2

City State

Zip Code

Birth Date *

Month Day Year

Phone Number *

This is my: *

E-mail

By providing your email, you agree to receiving appointment notifications and other communications.

Emergency Contact *

Phone Number *

How did you find out about GalactiCenter Bodyworks?

Occupation

Medications (include pain relievers & herbal remedies)

Allergies (include nuts, oils, or detergents)

Rate your stress level

	1	2	3	4	5	6	7	8	9	10

1 is low, 10 is high

Describe your overall health

Are you currently under the care of a

Physician Chiropractor Physical Therapist Occupational Therapist Acupuncturist

Please list the names of your practitioners:

History of Pathology

1. List Areas of Discomfort or Pain

2. Describe Onset of Discomfort or Pain and Rate Pain on a scale 1-10 (10 worse pain)

4. Frequency - please select the most accurate

Constant Off/On At Rest With Activity

5. At what time of day is the pain at its worse?

Morning Afternoon Evening During Sleep

6. Have you ever injured this area before?

7. Have you ever been in an accident (automobile, work, falls, etc.) ? *

8. List all related treatments received for this injury.

9. Have you ever received therapeutic massage for a specific problem or injury?

Was the treatment used effective?

10. Is there anything that you do that creates, increases or decreases pain?

11. What are the physical duties required of your occupation?

13. 12. What activities/hobbies do you enjoy? Please list exercise and stress reduction activities.

How often do you exercise

less than 3 x per week 3-6 x per week everyday

14. In what position do you most often wake up?

Back Side Stomach

How long do you sleep most nights?

less than 6 hours 6-8 hours more than 8 hours

Please check any symptoms that apply to you:

General Conditions

Headaches Pain Sleep disturbances Fatigue Infections Fever Sinus

Nervous System Conditions

Muscles & Joint Conditions

Cardiovascular Conditions

Digestive/elimination Conditions

Bowel problems Gas, bloating Bladder/ kidney Prostate Abdominal pain

Skin Conditions

Rashes Athlete's foot/ warts

Endocrine Conditions

Thyroid Diabetes Autoimmune disorder

Cancer/tumor Conditions

Benign Malignant

Do you have any other conditions or specific medial complaints that may be affected by massage therapy?

Are there any area of concern you'd like to address that wasn't covered in the form? If so, please discuss.

Circle any areas of discomfort

MASSAGE POLICIES:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please turn off your cell phone for optimal relaxation

• Your scheduled session is set aside for you. We do not double book appointments

• Please reschedule your session if you are more than 15 minutes late

• 24 hour cancellation notice is required to avoid being charged for your session

• You will be draped and at no time will genitalia or breast tissue be exposed

• You will have a consultation with your therapist to discuss your session

• Should the session require, after your therapist has left the room, you may disrobe to your comfort level

• I understand that my therapeutic massage therapist or I may end the session at any time for any reason

• Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

CLIENT AGREEMENT:

I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic massage as a form of therapy.

I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless GalactiCenter Bodyworks and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

COVID-19

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. I understand the benefits and risks associated with the provision of health care during a pandemic.

I confirm I am not experiencing any of the following symptoms of COVID-19 listed: Fever, shortness of breath, dry cough, sore throat, runny nose, loss of taste or smell

I understand that both the therapist and myself are required to wear a mask during the session with the exception to when I am in prone position (faced down).

PARENT/GUARDIAN WAVIER FOR MINORS:

If the client is less than 18 years old, the Client’s parent and natural guardian hereby represents that he/she is,
in fact, acting in that capacity, has consented to his/her child or ward’s availing of the services of GalactiCenter Bodyworks, LLC, and has agreed individually and on behalf of the child or ward, to the terms of this “Informed Consent and Wavier”. The undersigned parent or guardian further agrees to save and hold harmless and indemnify GalactiCenter Bodyworks, LLC from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon GalactiCenter Bodyworks, LLC relating to massage therapy and body work on behalf of the Client and all of the Client’s parents or legal guardians.

By my electronic signature below, I agree to the massage policy and client agreement above.

Date

Client Signature or Parent/Guardian if under 18 years of age *

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear