Copy and paste into a word document to complete before coming into your first session to save on time.

Health Intake Form

Dotson Massage & Bodywork LLC

Confidential Form

Basic Information

First Name___________________________________

Last Name_______________________________________

Date of Birth__________________________________Occupation_______________________________________

Referred By:_______________________________________________

Contact Information

Email_______________________________________________________________________________________

Preferred Phone_______________________________________________________________________________

Address________________________________________________________   City_________________________   

State___________________________________             

Postal Code______________________________

Emergency Contact Information

Contact Name____________________________

Phone __________________Relationship__________________

Doctor Information

Physician Name__________________________  Phone___________________

Complaints

Cause of Injury or Concern______________________________________________________________________

____________________________________________________________________________________________

How long since first notice_______________________________________________________________________

____________________________________________________________________________________________

Primary Complain______________________________________________________________________________

____________________________________________________________________________________________

Past Treatment________________________________________________________________________________

____________________________________________________________________________________________

Existing Conditions_____________________________________________________________________________

____________________________________________________________________________________________

Respiratory

 Asthma                              Shortness of Breath                 Bronchitis                          Chronic cough  

 Emphysema

Cardiovascular

 Blood Clots                        High Blood Pressure              Low Blood Pressure            Stroke

Varicose Veins                    Cardiovascular Accident         Heart Disease                   Pacemaker

 Phlebitis                             Cerebral-vascular Accident    Heart Attack                        Lymphedema

 Myocardial Infarction         Thrombosis/Embolism            Congestive Heart Failure    Cold Hands        Cold Feet

Skin

 Bruise Easily                     Skin Irritations                         Hypersensitive Reaction             Melanoma                          Skin Conditions

Head & Neck

 Ear Problems                      Migraines                               Headaches                      Sinus Problems

 Hearing Loss                      Vision Loss                             Jaw Pain (TMJD)            Vision Problems

 

 

Infectious Conditions

 Athlete's Foot                      Respiratory Conditions            Hepatitis                         Skin Conditions Herpes                                HIV

Women

 Gynecological Conditions                     Pregnancy

Soft Tissue / Joint Dysfunction

Ankles (Left)   Feet (Left)    Hips (Left)   Legs (Left)    Mid Back (Left)      Shoulders (Left)

Ankles (Right  Feet (Right)  Hips (Right) Legs (Right) Mid Back (Right)   Shoulders (Right)

Arms(Left)    Hands (Left)   Knees (Left)  Lower Back (Left)    Neck (Left)Upper Back (Left)

Arms(Right) Hands (Right) Knees (Right)Lower Back (Right) Neck (Right)Upper Back                           

                                                                                                                                                                        (Right)

Family History

 Cardiovascular Conditions                                      Respiratory Conditions

Miscellaneous

 Allergies                     Cancer                Dizziness                  Hemophilia           Mental Illness

 Gout                           Stress                  Anaphylaxis             Crohn's Disease   Epilepsy           

 Insomnia                    Osteo Arthritis     Rheumatoid Arthritis  Arthritis                Lupus                

 Digestive Conditions  Diabetes              Fibromyalgia             Shingles               Osteoporosis         Loss of Sensation       Other Medical Conditions                           Other Diagnosed Diseases                           Artificial Joints / Special Equipment              Surgical Pins or Wire                            

Allergies and other conditions your provider should be aware of

Neurological

 Burning                     Numbness                   Cerebral Palsy                   Parkinsons

 Herniated Disc          Stabbing                     Multiple Sclerosis               Tingling

Medications Please list any medications or drugs you are currently on

Client Waiver form

Please take a moment to read and initial the following information

• I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
• If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
• I understand that I should see a physician, chiropractor or other qualified medeical specialist for any mental or physical ailment that I am aware of.
• I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat 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 notified my therapist of all known medical conditions and injuries and answered all questions honestly.
• I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.
• I understand that massage is entirely therapeutic and non-sexual in nature. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
• By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
• Draping will be used during the session-only the area being worked on will be uncovered. 
• Clients under the age of 16 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 18.
• All information provided to Dotson Massage & Bodywork LLC by you, the consumer, will always be kept safe and confidential and will never be sold or abused.

                                                                                                                                                 

      I have read the statement above and agree to all the policies

Client Signature* _____________________________           Date*_______________________________

(If client is under 18 years of age)

Parent/Guardian Signature*________________________________     Date*_______________________________

 

Screening Questionnaire form
Body Map for Clients
Health Status Update form
Client Feedback form
Physician's Permission form
Physician's Referral form