Client Intake Form Client Intake Form-Fascia Therapy/Massage First and Last Name:* Home Address:*Phone number:* E-mail Address:* Have you had a professional massage or fascia blasting treatment before? YesNo If yes, how often do you receive massage therapy?*Do you have any difficulty lying on your front, back, or side?Yes No If yes, please explain*Do you have any allergies to oils, lotions, or ointments?Yes No If yes, please explain*Do you sit for long hours at a workstation, computer, or driving?Yes No If yes, please describe*Do you have sensitive skin?* Yes No Do you wear contact lenses?* Yes No Do you wear dentures?* Yes No Do you perform any repetitive movement in your work, sports, or hobby?Yes No If yes, please describe*What particular area of the body do you are experience tension, stiffness, pain or other discomfort?*Do you have any particular goals in mind for this session/treatment?Yes No If yes, please explain.*Do you see a chiropractor? Yes No If yes, how often?*Are you currently taking any medication?Yes No If yes, please list.*Check any condition listed below that applies to you: (check all that apply).* contagious skin condition open sores or wounds easy bruising recent accident or injury recent fracture recent surgery artificial joint sprains/strains current fever swollen glands allergies/sensitivity heart condition high or low blood pressure circulatory disorder varicose veins atherosclerosis phlebitis deep vein thrombosis/blood clots joint disorder/rheumatoid arthritis/osteoarthriitis/tendonitis osteoporosis epilepsy headaches/migraines cancer diabetes decreased sensation back/neck problems fibromyalgia TMJ carpal tunnel syndrome tennis elbow Please explain any condition that you have marked above:Are you currently pregnant? If yes, how many months?*Is there anything else about your health history that you think would be useful for us to know*I understand that draping will be used during massage or fascia blasting sessions – only the area being worked on will be uncovered.* Yes No I understand if I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.* Yes No Because massage should not be performed under certain medical conditions, I have stated all my known medical conditions, and answered all questions honestly.* Yes No Because massage should not be performed under certain medical conditions, I have stated all my known medical conditions, and answered all questions honestly.* Yes No I agree to keep the therapist updated as to any changes in my medical prole and understand that there shall be no liability on the therapist’s part should I fail to do so.* Yes No I agree to keep the therapist updated as to any changes in my medical prole and understand that there shall be no liability on the therapist’s part should I fail to do so.* Yes No I agree to release and discharge Patti Garland and her company Healthy Methods Wellness from all claims or causes of action (known or unknown) arising out of my negligence.* Yes No I acknowledge that I have carefully read this waiver and Release and fully understand that it is a release of liability. I am waiving any right that I may have to bring a legal action to assert a claim against my therapist for his/her negligence.* Yes No FacebookInstagramEmail
