EmailMe Form - Island Healing Medical Intake Form

Client Name *

First Last

Age *

Email *

Phone *

### - ### - ####

1. List Areas of Discomfort or Pain: *

2. Have you ever been in an accident (automobile, work, falls) ? *

No

Yes

3. Are you currently seeing other healthcare professionals?

No

Yes

4. Have you ever received therapeutic massage for a specific problem or injury?

No

Yes

5. Please indicate exercise/stress reduction activity level.

Low

Moderate

High

Excessive

6. Please list any known allergies or skin conditions.

Note any reaction to essential oils, powders or lotions.

7. Are you currently pregnant?

No

Yes

Maybe

8. Musculoskeletal Pain

Fractures/Dislocation

Osteoarthritis

Rheumatoid

9. Gastronomical

IBS

Colitis

Crohn's Disease

10. Headache History

11. Cardiovascular

12. Client Agreement and Declaration

> I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

> I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

> It is my choice to receive therapeutic massage as a form of therapy.

> I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

> I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.

> I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

> I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Island Healing from any liability whatsoever arising from failure on my part.

> By my form submission dated below, I agree to the massage policy and client agreement above.

Date of Intake Form. *

MM / DD / YYYY