Client Intake Form Name(Required) First Last Phone(Required)Email(Required) Emergency Contact Name(Required) First Last Emergency Contact Phone(Required)Consent I agree for my therapist to follow up with me to ensure my satisfaction with my massage experiencePreferred form of communication(Required) Phone Call Text Email Select AllWould you like email updates from Lime Green Lotus, e.g. on new services and special offers/discounts?(Required)YesNoSection Break The following information will be used to help plan safe and effective massage sessions. Please answer the following questions to the best of your knowledge.Have you had a professional massage before?(Required)YesNoIf so, how often?(Required) Do you have any difficulty lying on your front, back or side?(Required)YesNoIf so, please explain.(Required) Do you have sensitive skin or allergies to oil, lotion, or ointment?(Required)YesNoIf so, please explain.(Required) Do you have any other allergies?(Required)If none, type "none". Do you sit for long hours at work or driving, or perform any repetitive movement in your work, sports, or hobbies?(Required)YesNoIf so, please describe.(Required) Do you experience stress in your work, family or other aspects of your life?(Required)YesNoIf so, how do you think it has affected your health(Required) Muscle tension Anxiety Irritability Other Define "other"(Required) Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?(Required)YesNoIf so, please identify(Required) Do you have any particular goals in mind for this massage session?(Required)YesNoIf so, please describe(Required) Medical HistoryAre you currently under medical supervision?(Required)YesNoIf so, please explain.(Required) Do you see a chiropractor?(Required)YesNoIf so, how often?(Required) Are you currently taking any medications?(Required)YesNoCheck all that apply(Required) Coumadin Lovenox Heparin Plavix High-dosage aspirin or ginger Pain killers Muscle relaxants Other(s) Please list any other medications(Required)Do you have (check all that apply)(Required) None Phlebitis/Deep vein thrombosis/Blood clot/Varicose veins Heart condition (pacemaker?) Joint disorder/Rheumatoid Arthritis/ Osteoarthritis/Tendonitis Osteoporosis Open sores or wounds Current fever, flu, cold or swollen glands Recent accident or injury (specify) Artificial joint MRSA or other infectious diseases Epilepsy Headaches/Migraines Neuropathy (decreased sensation) Atherosclerosis Scoliosis or lordosis; herniated discs (where?) Hemorrhoids Aneurism High or low blood pressure (controlled?) Fibromyalgia Easy bruising Contagious or inflammatory skin condition, cellulitis, boils, skin lesions or abscesses Surgery within the last year or implants within the last nine months (cheek, chin, breast, pectoral, calf) Sprain/Strain/Fracture/Break Carpal tunnel Tennis/Golfer’s elbow TMJ Cancer (cancer medication?) Diabetes Pregnancy (which trimester?) Circulatory disorder Kidney or liver disorder (including dialysis) Lumbar spinal stenosis, spondylitis or spondylolisthesis Irritable bowel syndrome Specify your recent accident or injury(Required) Where is your scoliosis or lordosis; herniated discs?(Required) Is your blood pressure controlled?(Required) Are you on medication for your cancer?(Required) Which trimester is your pregnancy?(Required) Is there anything else about your health history that is important to plan a safe and effective massage session for you and your massage therapist?(Required)ConsentA parent or legal guardian must accompany clients under the age of 18 and provide informed written consent.Consent(Required) I understand that the massage 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 will immediately inform the therapist so that the pressure and/or stroke may be adjusted to my level of comfort. I further understand that the massage should not be construed as a substitute for medical examination, diagnosis or treatment. I understand that massage therapists are not licensed 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 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 change in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. Full Name(Required) Type your full name to serve as your signatureToday's Date(Required) PhoneThis field is for validation purposes and should be left unchanged.
