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Why Us
Massage Therapy
Therapeutic Massage
Sports Massage
Prenatal Massage
Lymphatic Drainage Massage
Facial Spa
HydraFacial
Microcurrent Facials
FSM Services
Products
Contact Us
Massage Intake Form
We look forward to hearing from you.
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Contact Information
Your Name
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First
Last
Phone
*
Birth Date
MM slash DD slash YYYY
Email
*
Basic Medical / Physical Information
Medications
Add
Remove
Allergies
Add
Remove
Areas of Discomfort / Pain
Onset of Discomfort / Pain
How much pressures during the massage
Very Little
Very Deep
Rate of Pain
Very Little
Very Deep
Describe the frequency of your pain
Is there anything you do that creates, increases or decreases pain?
If so, provide details
Please check any symptoms that apply
Head Symptoms
Temples
Forehead
Top of Head
In the Eyes
Entire Head
Base of Skull
Dizziness
Fainting
Light-headedness
Pain in Ears
Ringing in Ears
Other
Other Head Symptom
Neck Symptoms
Stiffness
Pain in neck shoulder junction
Pain when turning head
Pain with side-to-side movements
Neck feels out of place
Muscle spasm in neck
Gliding / Grating shound w/ neck movement
Diagnosed bone spurs
Diagnosed disc herniation
Other
Other Neck Symptom
Shoulder Symptoms
Pain in shoulder
Front
Back
Side
Pain deep in shoulder joint
Diagnosed bursitis
Diagnosed arthristis
Can't raise arm over head
Can't raise are over shoulder level
Other
Other Shoulder Symptom
Arms & Hands Symptoms
Pain in upper arm
Pain in forearm
Pain in wrist
Pain in fingers
Sensation of pins & needles in arms
Sensation of pints & needles in fingers
Fingers go to sleep
Hands cold
Swollen joints in fingers
Sore joints in fingers
Diagnosed arthritis
Loss of grip strength
Other
Other Arms & Hands Symptom
Mid-Back Symptoms
Mid-back pain
Pain between shoulder blades
Pain up/down back
Pain across mid back
Pain with breathing
Other
Other Mid-Back Symptom
Low-Back Symptoms
Low back pain
Pain is worse when working
Pain is worse when lifting
Pain is worse when stooping
Pain is worse when standing
Pain is worse when sitting
Pain is worse when bending
Pain is worse when coughing
Pinched nerve in low back
Low back feels out of place
Pain up/down low back
Pain across low back
Diagnosed disc herniation
Other
Other Low-Back Symptom
Hip Symptoms
Pain in buttocks
Pain in buttocks when standing
Pain in buttocks when sitting
Pain on side of hip
Pain deep in hip joint
Pain on sit bone
Diagnosed bursitis
Diagnosed arthritis
Other
Other Hip Symptom
Legs & Feet Symptoms
Pain down RIGHT leg
Pain down LEFT leg
Pain down BOTH legs
Leg cramps
Pin & Needles in RIGHT leg
Pin & Needles in LEFT leg
Numbness in RIGHT leg
Numbness in LEFT leg
Numbness in RIGHT foot
Numbness in LEFT foot
Numbness in toes
Feet feel cold
Cramps in RIGHT foot
Cramps in LEFT foot
Swollen RIGHT ankle
Swollen LEFT ankle
Swollen RIGHT foot
Swollen LEFT foot
Pain in RIGHT foot
Pain in LEFT foot
Pain in RIGHT knee
Pain in LEFT knee
Diagnosed Arthristis
Other
Other Leg & Feet Symptom
Information About Your Appointment
Client information is confidential and written authorization is required to release any information.
We do not double book appointments
Please reschedule session if more than 20 minutes late
24 hour cancellation notice is required
You will be draped and at no time be exposed
You will have a consultation with your therapist to discuss the session
You my 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 therapy does not diagnose and heal illness, disease, any physical or mental disorder.
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.
I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction.
I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist.
I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.
By my electronic signature below, I agree to the massage policy and client agreement above.
Signature
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