Client Intake Form - Healthy Methods Wellness

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).*

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