Client Intake Form

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Apex Bodyworks Massage Client Intake Form Date: Client Name:_________________________________Tel:_________________D.O.B._____________ Address___________________________________City:_________________State:____Zip:________ Occupation___________________Email:____________________Referred by:___________________ Skin & Hair

Significent Illnesses

☐ Cancer

☐ Osteoporosis

☐ Rashes

☐ Shingles

☐ Scabies

☐ Diabetes

☐ Heart Attack

☐ Eczema

☐ Skin Lesions

☐ Lice

☐ Seizures

☐ Trauma

☐ Psoriasis

☐ Boils

☐ Cellulitis

☐ Occupational Stresses

☐ Allergies to oils/scents ☐ Warts

☐ Infectious skin disease Cardiovascular

☐ Transmittable Diseases: ____________________ ☐ Medications: _____________________________ ☐ High BP

☐ Clotting Disorders

______________________________________ ☐ Low BP

☐ Pressure Phlebitis

☐ Exercise Regimen: _________________________ ☐ Chest Pain

☐ Varicose Veins

☐ Palpitations

Musculoskeletal

☐ Anemia

☐ Neck Pain, Where?

☐ Swollen Hands/Feet ☐ Heart Disease

☐ Muscle Pain? - Where?

☐ Dizziness/Fainting Is it medically controlled? Respiratory

☐ Back Pain? - What area(s)? ☐ Sprains or Strains? - Where?

☐ Asthma

☐ Emphysema

☐ Joint Pain? -Where?

☐ Sinus Trouble

☐ Chest Pains

☐ Carpal Tunnel Syndrome ☐L ☐R ☐Fixed

☐ Shortness of Breath ☐ Difficulty Breathing Head, Eyes, Ear, Nose, Throat

☐ Fibromyalgia ☐Thoracic Outlet Syndrome

☐ Neck Pain

☐ Grinding Teeth

☐ Other Joints/Bone Problems?

☐ Migraines

☐ Facial Pain

☐ Eye Pain

☐ Headaches ☐ Jaw Clicks

General

☐ Sleeping Problems

☐ Bleed/Bruise

☐ Earaches

☐ Cold Hands/Feet

☐ Pins and Needles

☐ Numbness Hands/Feet

☐ Fevers

☐ Surgeries/when: __________________________ _________________________________________

Have you ever had a professional massage before? Yes☐

No☐ How long ago?

Are you or is there a chance that you may be pregnant? Yes☐ Your reason for getting massage today:

No☐ How long?

☐ Relaxation ☐ Therapy ☐ Both

Please circle the areas of your body that you allow me to massage Back

Legs

Buttocks

Arms Hands

Abdomen

Chest

Neck

Head

Face

Feet

Are you under the care of a Dr? ☐ yes

☐ no

Dr's name and phone number ____________________________________ May I contact:

☐ yes

☐ no

Please describe your current complaint or limitation: ________________________________________________

___________________________________________________________________________ What is your goal for therapy? __________________________________________________________________

__________________________________________________________________________________ Please describe the nature of your pain:

☐ Sharp Pain

☐ constant (76%-100%)

☐ Dull Pain

☐ frequent (51%-75%)

☐ Throbbing Pain ☐ occasional (26%-50%) ☐ Numbness

☐ intermittent (25% or less)

☐ Shooting ☐ Burning ☐ Tingling Indicate the intensity of your pain at rest:

No Pain 0 1 2 3 4 5 6 7 8 9 10 Unbearable Pain

Indicate the intensity of your pain with movement:

No Pain 0 1 2 3 4 5 6 7 8 9 10 Unbearable Pain

What movement causes the pain to increase? _____________________________________________________

Since this condition began your symptoms have: ☐ decreased ☐ not changed ☐ increased Your symptoms are worse in: ☐ morning ☐ afternoon ☐ night ☐ same all day When did your problem begin? ☐ days ago ☐ months ago ☐ years ago Specific date: ____/____/_____ What makes your problem better?

☐ nothing ☐ Lying down ☐ standing ☐ time ☐ sitting ☐ movement/ exercise ☐ inactivity

What makes your problem worse?

☐ nothing ☐ Lying down ☐ standing ☐ sitting ☐ movement/ exercise ☐ inactivity

What kind of music do you like? ________________________________________________________ Please list any other issues you feel are important for me to know ______________________________________

___________________________________________________________________________ __________________________________________________________________________________________

The type of massage therapy I anticipate on using could include any of the following: deep tissue, Swedish, Shiatsu or Sports. Hydrotherapy may also be used, to help relax your muscles. The massage therapy session will focus on your neck, back, legs, arms, excluding any contraindicated areas. Communication is key and if you need me to increase or decrease the pressure, please speak up. If at any time you feel uncomfortable for any reason, you may ask me to cease the massage and I will immedialtely end the session. According to the Oregon State Department of Health and my own policy, draping will be used at all times.

Cancellation/Late Policy: I understand that unanticipated events happen occasionally in everyone’s life. Business meetings, project deadlines, flight delays, car problems, snowstorms, and illness are just a few reasons why one might consider canceling an appointment. In my desire to be effective and fair to all of my clients and out of consideration for my time, I have adopted the following policies: • 24 hour advance notice is required when canceling an appointment. This allows the opportunity for someone else to schedule an appointment. • If you are unable to give me 24 hours advance notice you will be charged the full amount of your appointment. This amount must be paid prior to your next scheduled appointment. No-shows Anyone who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a “no-show”. They will be charged for their “missed” appointment and future service will be denied until payment is made. Arriving late Appointment times have been arranged specifically for you. If you arrive late your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, I will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the “full” session. Out of respect and consideration to me, your therapist and other customers, please plan accordingly and be on time. I LOOK FORWARD TO SERVING YOU.

Please read the following statement Carefully, and then sign below. I fully understand that massage

therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any medical ailments that I may have. Since a massage therapist must be made aware of any excisting physical conditions, I have stated all known medical conditions and take it upon myself to keep the therapist updated on my physical health. I understand that deep tissue massage may cause some after effects that may be uncomfortable , such as an increase in urination, soreness and feeling tired. I understand that payment is due at time of treatment. I understand that any remarks or actions of a sexual or personal nature will result in immediate termination of session and no furture appointments will be honored. I have carefully read and undrstand all of the above and I have answered all questions fully and accurately.

Client Signature:_____________________________ Date:_____________

Therapist Signature:__________________________ Date:_____________

Date: Subjective:

Objective:

Assessment:

Plan:

Notes: