Questionnaires
Intake Questionnaire
First Name:
Last Name:
Email:
Address:
Phone:
Date of Birth:
Employer:
Occupation:
Emergency Contact:
Emergency Contact Phone:
Is this you first professional massage?
If no, how frequently do you get a massage?
Describe Any Surgeries, Hospitalizations, Accidents Or Injuries You Have Had:
What Kind Of Care Did You Receive For Your Accidents Or Injuries?
Do You Feel That You Have Recovered From These Events?
Do You Have Any Chronic, Ongoing Pain That You Deal With On A Regular Basis?
Describe What Activities Cause This Pain And/or Make It Worse:
Are You Receiving Any Other Type Of Medical Treatment?
Please List Any Medication (Vitamins, Herbs Or Pharmaceutical) Taken Now Or At Regular Intervals (Include Explanation Of What Medication Is Used To Treat):
Are You Currently Under The Care Of A Physician?
Whom?
Please List Reason(S):
Please Describe Any Other Health Concerns You Wish To Discuss Today?
Are you currently experiencing any of the following conditions?
Flu or Cold
Infection
Inflammation
Contagious Disease
Fever
Please check any of the following conditions below that currently affect you or that you have experienced in the last 5 years.
Musculoskeletal
Fibromyalgia
Osteoporosis
Osteoarthritis
Rheumatoid Arthritis
Cysts
Tendonitis
Carpal Tunnel Syndrome
Headache
Low Back Pain
Spasms/Cramps
Postural Deviations
TMJ
Plantar Fasciitis
Torticollis
Sciatica
Leg Pain
Mid Back Pain
Sprains/Strains
Gout
Whiplash Syndrome
Thoracic Outlet Syndrome
Arm Pain/Shoulder Pain
Hip Pain
Additional details:
Respiratory
Pneumonia
Sinusitis
Asthma
Trouble Breathing
Dizziness
other
Additional details:
Circulatory
Anemia
Low Blood Pressure
Heart Condition
Hemophilia
Raynaud's Disease
Blood Clots/Phlebitis
Hypertension
Varicose Veins
Diabetes
Other
Additional details:
Digestive
Ulcers
Gallsotnes
Diarrhea
Irritable Bowel Syndrome
Hepatitis
Gas/bloating
Colitis
Crohn's Disease
Indigestion
Additional details:
Skin
Fungal Infections
Dermatitis/Eczema
Rashes
Acne
Psoriasis
Warts/mole
Impetigo
Open Wound or Sore
Additional details:
Nervous System
ALS
Bell's Palsy
Stroke
Numbness/tingling/twitching
Multiple Sclerosis
Neuritis
Trigeminal Neuralgia
Parkinson' Disease
Spinal Cord Injury
Seizure Disorders
Additional details:
Other:
Insomnia
Grief Process
Pregnancy
Lupus
Postoperative Situation
Anxiety/panic attacks
Cancer
Chronic Fatigue
Kidney Disease
Edema
PMS
Substance Abuse
HIV/AIDS
Bladder Infection
Additional details:
The above information is accurate and true to the best of my knowledge. I understand that massage therapists do not diagnose disease, prescribe medications bones. I further understand that message therapy is not a substitute for medical attention or examination. I take responsibility for altering my practitioner to any physical, mental or emotional changes that occur with my health. I also understand that cancelled or missed appointment without 24 hours notice (medical emergencies excluded) may be charged in full for the price of the missed session.
Send
Before Your Appointment
Please check any that apply to you:
- Have you had a new or worsening cough?
- Have you had a fever?
- Have you had shortness of breath?
- Have you been in close contact with anyone with these symptoms f anyone who has been diagnosed with Covid-19 in the past 14 days?
-IF YOU ANSWERS “YES” TO ANY OF THE QUESTIONS ABOVE, I WILL NEED TO RESCHEDULE YOUR APPOINTMENT UNTIL YOUR SYMPTOMS (COUGH, FEVER AND SHORTNESS OF BREATH) HAVE BEEN RESOLVED, FOR AT LEAST 14 DAYS AFTER AND IF YOU THINK YOU HAD CONTACT WITH A PERSON SICK WITH COUGH, FEVER, OR DIAGNOSED COVID-19. WE RESERVE THE RIGHT TO CANCEL UPON YOUR ARRIVAL IF NECESSARY. THE DOOR WILL REMAIN CLOSED JUST TEXT OR LEAVE A MESSAGE WHEN YOU ARE OUTSIDE. I WILL CONTACT YOU WHEN READY FOR YOUR APPOINTMENT. WE ARE FOLLOWING ALL RECOMMENDED OSHA, AMTA AND CDC GUIDELINES, WE ASK THAT YOU WEAR A MASK DURING YOUR VISIT ( IF YOU DO NOT HAVE ONE THERE WILL BE SOME AVAILABLE FOR YOU AT 1.50 EACH) PLEASE DO NOT MAKE YOUR APPOINTMENT RIGHT AFTER EXERCISING. REVIEW AND FILL OUT FORMS ON LINE BEFORE YOUR APPOINTMENT. ONLY THE PERSON WITH THE APPOINTMENT WILL BE ALLOWED IN, EXCEPT SPECIAL NEED CLIENTS.
Signature:
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Covid-19 Liability Waiver
I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless Willis Day Spa from any claims related thereto. I give my consent to receive treatment from this practitioner. *
Signature:
Date:
Parent or Guardian Signature (In case of Minor):
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