General Health Intake Form

Name *

First

Last

Email *

Phone *

EMERGENCY CONTACT INFORMATION NAME *

First

Last

Who would you like us to contact in the event of an emergency?

EMERGENCY CONTACT PHONE

How would you rate your overall general health? *

Excellent
Good
Fair
Poor

Have you had a professional massage before?

Yes
No

Are you able to climb or descend more than 10 stairs in a staircase without pain or difficulty?

Yes
No

Please list any allergies or hypersensitivities? (Coconut oil, peanuts or any Essential oils) *

List any major accidents or surgeries (including dates)

What is your reason for this initial visit?

NERVOUS SYSTEM

Sensory loss / change
Sciatica
Numbness / tingling
NONE

MUSCULOSKELETAL SYSTEM

CARDIOVASCULAR

SKIN & INFECTIONS

Lyme disease
Tuberculosis
Infectious skin conditions
NONE

Other Conditions

Cancer
Fibromyalgia
Chronic fatigue syndrome
NONE

Have you had a fever in the last 24 hours of 100°F or above? *

Yes
No

Have you recently had or are experiencing, any respiratory or flu-like symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)? *

Yes
No

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *

Yes
No

Have you had a new loss of sense of taste or smell? *

Yes
No

Have you received a dose of any COVID-19 (EUA) injection or Comirnaty vaccine? If yes, please indicate which manufacturer's injection you've received: *

If you've received any COVID-19 (EUA) injection, please provide the date that the dose was administered: *

If you have not received any dose, please type 'N/A' or NONE

If you've received any COVID-19 BOOSTER, please provide the date that the dose was administered: *

If you have not received any dose, please type 'N/A' or NONE

Informed Consent Signature *

First

Last

-- It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage. --