Download and Print the PDF 2020 BODY FIRST MASSAGE THERAPY INTAKE FORM or complete online Massage Therapy Client Intake Form 2020 Update for current clients Step 1 of 5 20% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Month Day Year Primary Phone*Secondary PhoneEMAILBody First utilizes your email to send email appointment notifications, email reminders, and to contact you when we are unable to contact by other means. Please choose to OPT-IN if you want to receive news, updates, and specials from Body First. Email* EMAIL OPT-IN: Body First Wellness I would like to receive email wellness news and updates from Body First.EMAIL OPT-IN: Body First Strong I would like to receive fitness specific new and updates from Body First.EMAIL OPT-IN: Body First Tennis I would like to receive tennis specific new and updates from Body First. Massage Therapy InformationHelp us provide you with a positive massage therapy experience. Please take the time to let us know what you are needing in a massage.Have you had a professional massage before?* Yes No If yes, How often do you recieve massage therapy?* Are you currently a Body First Client?* Yes No What type(s) of massage therapy or bodywork are you seeking during your session?* Select All Massage Therapy for Relaxtion Deep Tissue/Therapeutic Sports Massage Pregnancy Massage Other bodywork; Reflexology, Cupping, etc. If you chose Sports Massage what sports or athletic endeavors are you currently involved in or training for?*What is your goal for your next massage?*What kind of pressure do you prefer?*Very DeepDeepFirmGentleExtra GentleNot sureDo you have any difficulty lying on your back, front, or side?* Yes No Do you have any allergies to oils, or lotions or sensitive skin* Yes No If you do have any allergies please explain:Please explain what areas you are currently having muscle pain/tension. Health HistoryThough we are not required to by law, it is the intention of Body First to ensure the confidentiality and integrity of protected health information of both clients, members, and employees as required by HIPAA, professional ethics, licensure requirements, and any other legal requirements. At this time our website has a SSL Certificate, is PCI compliant, and we have enacted numerous protocols to protect your data and we do not store any personal health information in our database. At this time we have taken the numerous steps to ensure your information is safe and secure we are still working integrating our website to be HIPAA compliant. If you do not wish to answer any of the following questions online, we will collect this information at the time of your appointment. Are you currently experiencing any discomfort of pain? Yes NO If yes, for how long have you had this pain or discomfort? Do you know what caused the pain or discomfort and what makes the symptoms better of worse?Do you see a chiropractor? Yes No If yes, for how long? Are you currently on Aspirin Therapy or taking any other blood thinners? Yes No Are you on any additional medications the therapist should be aware of? If so what?Please mark the conditions you are experiencing or have in the past. Aids/ HIV Arthritis Back Pain Bursitis Chronic Fatigue Diabetes Headaches/migraines High blood pressure Major accident Muscle/ joint problems Pregnancy(Due Date:______) Sinusitis Recent surgeries: Varicose veins Allergies Asthma Blood clots Bruise Easily Cancer/Tumors Chronic Pain Dizziness Heart disease/ Stroke Leg pain Neck pain Numbness Sciatica Skin conditions List any additional conditons not listed Please explain of the conditions listed above. Your Treatment-ConsentPlease take a moment to read and agree the following statements regarding your treatment. By checking the boxes your are hereby affirming that you have read, fully understand and therefore consent to participating with Body First in programs and services within the framework stated below and in Body First's Privacy PolicyPrivacy Policy* I agree to the privacy policy.*Body First Policy Privacy Scheduling and Cancellation Policies* I agree to the Scheduling and Cancellation Policies.*Body First Policy Privacy Massage Therapy for wellness* Massage Therapy for wellness*I understand that the services I receive is provided for the purpose of wellness and body maintenance and services may include modalities that are designed to enhance physical fitness, mental attitudes, and alertness. Client Health Warranty* Client Health Warranty*I am not aware of any disability, impairment, or ailment preventing me from receiving massage therapy. I affirm that I have stated all my known medical conditions and injuries and answered all questions honestly. I agree to keep the massage therapists updated as to any changes in my health profile, and understand that there shall not be liability on the massage therapist’s part should I forget to do so. Massage Therapist role in client wellness.* Massage Therapist role in client wellness.*I understand that massage therapists are not qualified to diagnose or prescribe for disease conditions and that nothing said, done, performed, typed, printed or produced is intended or meant to diagnose, prescribe, treat a disease or takes the place of a licensed physician, chiropractor, registered dietitian or other qualified health professional. I understand that body maintenance assessments and suggestions are intended only for the support of optimal health and do not involve diagnosing, prognosticating or prescribing any remedies for the treatment of disease conditions.Client responsibility for their wellness* Client responsibility for their wellness*I understand that I accept total responsibility for my own health care and maintenance and that I should seek treatment from a physician, chiropractor, registered dietitian or other qualified medical specialist for any medical conditions that I am aware of.Clients right to manage their massage therapy session* Clients right to manage their massage therapy session*. I understand that I accept total responsibility for my own health care and maintenance and that I should seek treatment from a physician, chiropractor, registered dietitian or other qualified medical specialist for any medical conditions that I am aware of.Therapist’s right to refuse service.* Therapist’s right to refuse service.*I understand that the therapist may choose to end any massage therapy session if they believe massage therapy could be detrimental to the client, the client is under the influence of drugs or alcohol, or the client exhibits any inappropriate behavior towards the therapist. Professional Draping* Professional Draping*For all services that require the client to undress; professional draping will be used during the session. CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
