Hill Country Healing Arts & Massage

Healing The Hill Country since 2002

Client Forms

 Hill Country Healing Arts & Massage                                         Client Intake Form 

Name_________________________________________________ 

Phone (Day) ____________________Cell____________________ Text or Call for follow up ___________

City and State      ___________________________________

Email ( optional - I don't send anything unless requested )______________________________________ 

Occupation (opt)_________________________________

Month/Day of  Birth____________________________

Referred by _______________________Web,Google, Yelp or Facebook Search_______________________________

Emergency Contact ___________________________________Phone_____________________________

Have you had a professional massage before? Yes __No__ If yes, how often? ___________

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, ointments, fruits or nuts? Yes___No___

If yes, please explain ______________________________________________________________

Do you have sensitive skin? Yes__ No__

Are you wearing  contact lenses  dentures  a hearing aid  prosthetics?_______________

Do you sit for long hours at a workstation, computer, or driving? Yes____ No____

If yes, please describe _____________________________________________________________

Do you perform any repetitive movement in your work, sports, or hobby? Yes___ No___

If yes, please describe _____________________________________________________________

Do you feel that stress in your workplace, home  or other aspect of your life affects your health?__________

Experience any muscle tension,  anxiety,  insomnia,  irritability  other___________________( circle any )

Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?

Yes__ No___ If yes, please identify____________________________________________________

Do you have any particular goals in mind for this massage session? Yes______ No________

If yes, please explain______________________________________________________________

Please describe any areas you would like the massage therapist to concentrate on during the session:

_______________________________________________________________________________________________

Medical History

Do you currently or have you ever had any medical issues you feel will impact your massage session?___________________

Do you easily bruise____ Any contagious skin condition ______recent accident or injury_______________open sores, cuts or wounds ________

Women Only - Pregnancy If yes, how many months?________ Any problems _____________ Menopause  __________

Do you see a chiropractor? Yes ___No____ If yes, how often?_____________Are you currently taking any medication? Yes _____   No______

If yes, please list _________________________________________________________________

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

Release -I understand that the massage I receive is provided for the basic purpose of relaxation and relief ofmuscular tension. If I experience any pain or discomfort during my session, I will immediately inform the therapist. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician 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 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.

 

Signature of client ___________________________________________  Date ___________________

 

Signature of Massage Therapist   ___________________________     Date ___________________