New Client Intake Form

/New Client Intake Form
New Client Intake Form 2017-03-03T20:26:54+00:00

Please complete this either form or the printable form when booking your first appointment. All information is private and confidential and will not be shared with third parties. For more information on how your information is used, please read The Grove Healing & Wellness Center privacy policy.

Your Name (required)

Your Email (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Phone

Gender MaleFemale

Date of Birth

Referred By (How did you hear about us?)

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you ever experienced a professional massage or bodywork session?
YesNo

If "Yes", how often do you receive massage therapy?

On a scale from 1 to 10, how deep of pressure do you prefer?
1 10

Do you have any difficulty lying on your back or side?
YesNo

If "Yes" please explain.

Do you have any allergies to oils, lotions, or ointments?
YesNo

If "Yes" please explain.

Do you have sensitive skin?
YesNo

Are you currently wearing
Contact LensesDenturesA Hearing Aid

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

If "Yes" please describe.

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

If "Yes" please describe.

Do you experience stress in your work, family, or other aspect of your life?
YesNo

If "Yes" how do you think it has affected your health?
muscle tensionanxietyinsomniairritabilityother

If "other" please describe.

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

If "Yes" please describe.

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

Medical History
In order to plan a massage session that is safe and effective, I need some general information about your medical history.

Are you currently under medical supervision?
YesNo

If "Yes" please explain.

Do you see a chiropractor?
YesNo

If "Yes" how often?

Are you currently taking any medication?
YesNo

If "Yes" please list.

Please check any condition listed below that applies to you:
contagious skin conditionopen sores or woundseasy bruisingrecent accident or injuryrecent fracturerecent surgeryartificial jointsprains/strainscurrent feverswollen glandsallergies/sensitivityheart conditionhigh or low blood pressurecirculatory disordervaricose veinsatherosclerosisphlebitisdeep vein thrombosis/blood clotsjoint disorder/rheumatoid arthritis/osteoarthritis/tendonitisosteoporosisepilepsyheadaches/migrainescancerdiabetesdecreased sensationback/neck problemsFibromyalgiaTMJcarpal tunnel syndrometennis elbowpregnancy (If yes, how many months?)other

Please explain any condition that you have marked above

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

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. 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. 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, chiropractor or 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 spinal or skeletal 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.

I HAVE READ AND AGREED TO THE FOLLOWING TERMS AND CONDITIONS

Would you like to be added to our mailing list?
YesNo

Draping will be used during the session – only the area being worked on will be uncovered.
Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.