Anyone care to share their intake form?

[Pompal 09.]

Hi - Just getting started and wondered if anyone has an intake form they feel is especially well done and would care to share. I searched the boards a bit but didn't find this ? elsewhere. Feel free to redirect me if it is. Or if you have a form in .doc or .pdf you would email. Or any links to websites with samples. I have one from school and one from a teacher. Just wondered... Ken

 

[jack h]

kencarl,
Did you check the FAQ section?
free form sites:
http://massageplanet.com/forum/viewtopic.php?t=456

 

[ERR0R]

Did you check the FAQ section?

actually... well... umm... no i somehow missed the whole 'read this first' part... i just searched. apparently badly. in the future i will note faqs first. thank you maestra

 

[divineintervener]

No problem kencarl, happy to be of help!

 

[Heidi D]

Anyone care to share their intake form?

Hi - Just getting started and wondered if anyone has an intake form they feel is especially well done and would care to share. I searched the boards a bit but didn't find this ? elsewhere. Feel free to redirect me if it is. Or if you have a form in .doc or .pdf you would email. Or any links to websites with samples. I have one from school and one from a teacher. Just wondered... Ken

Ken,
another thing you can do is google search massage intake forms... sometimes therapists have them on their websites for download for their clients to fill out. Once you look at a few, you can see what questions on them are relevant to the way that you work, and you can make your own. I was using a "standard" form, adn found that I did nothing with some of the questions on there, where there were other questions I would always verbally ask my clients.
Another thing which I really like is having a "body map" on my forms, where they can circle areas that they want focused on, and X out areas they dont want touched. This visual tool is really helpful.. during the massage you can close your eyes and picture what they circled and x'd out much easier than trying to remember what they said or wrote down... at least that's how it is for me.
To get a good body map, you can just find one on a soap note form.

Hope this helps!

 

[Latise J]

See generic form below...

 

[Raquel]

This is a generic form. Not exactly what I use, but should get you started.


Client Information

Name:____________________________
Phone: ( )_______-____________
Address:__________________________
Apt#:____________________
City:_____________________________
State:_______
Zip:_______________
Date of Birth:____________________
Fax#:____________________________
E-Mail:____________________________
Occupation:________________________
Referred by:_______________________
In case of emergency:______________
Phone: ( )_______-____________

General & Medical Information:
If you answer "yes" to any of the following questions, please explain as clearly as possible.

Yes No Have you ever had professional massage?
Yes No Have you had any broken bones in the past two years?
Yes No Do you experience frequent headaches?
Yes No Do you have tension or soreness in a specific area?
Yes No Are you pregnant?
Yes No Do you have cardiac or circulatory problems?
Yes No Are you wearing contact lenses?
Yes No Do you suffer from back pain?
Yes No Are you diabetic?
Yes No Do you have numbness or stabbing pains anywhere?
Yes No Do you have high blood pressure?
Yes No Are you very sensitive to touch / pressure in any area?
Yes No If yes to the previous question, are you taking medication for this?
Yes No Have you ever had surgery? If yes, please explain in the comments area of this form.
Yes No Do you suffer from seizure disorders or epilepsy?
Yes No Do you have any other medical condition that I should be aware of?
Yes No Do you suffer frequently from stress?

Comments:___________________________


PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED.

(If you have a specific medical condition or specific symptoms, massage / bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.) I understand that massage / bodywork 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 immediately inform the therapist so that the pressure and / or strokes may be adjusted to my level of comfort. I further understand that massage / bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should consult a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage / bodywork 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 / bodywork 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 therapists part should I neglect to do so. It is also understood 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.

Client
Signature:_______________________________________________________________________ Date:___________________________________

Therapist
Signature:_______________________________________________________________________ Date:___________________________________

Information and Suggestions for the Client

Prior to your massage, remove all jewelry. Pull long hair back with a clip.

As a rule, massage is given while you are unclothed. We provide a top sheet and / or towel. Modesty and comfort levels vary from person to person. You may choose to wear undergarments or a swim suit or nothing at all. This is YOUR massage and you should feel as comfortable as possible.

During your massage, you may want to give your therapist feedback as to pressure (deeper or lighter) or point out painful or ticklish areas of your body.

Feel free to ask your therapist any questions about their procedure. Your therapist is a highly trained professional and will be happy to make you feel well informed and comfortable.