Company We want to get to know you a little better! As a new member, we ask that you fill out the below intake form to tell us your wellness goals and any conditions you have that may restrict your treatment. All information is kept confidential. PERSONAL INFORMATION First Name * Last Name * Birth Date * Address/City/State/Zip * Email Address * Phone Number * Emergency Contact (Name/Relationship) Emergency Contact Phone Number Occupation/Employer Employer Phone Number Physician's Name Physician's Phone Number MASSAGE EXPERIENCE Have you had a professional massage before? Yes No If yes, what types of massage have you had? (Swedish, Shiatsu, Deep Tissue, etc.) How long have you been receiving Massage Therapy? How often do you receive massages? What are your goals for treatment? Stress relief Improve circulation Address target areas Relaxation To be refreshed/rejuvenated Other: CURRENT HEALTH Reason for initial visit? Height/Weight Do you exercise regularly and/or participate in sports? Yes No If yes, what kind of exercise/sports? Do you perform any repetitive movement in your work, sports or hobby? Yes No If yes, describe. Do you sit for long hours? Yes No If yes, describe. Do you experience stress in your work, family or other aspect of your life? Yes No If yes, describe. Are you experiencing tension, stiffness, discomfort or pain? Yes No If yes, describe. Have you recently had an injury, surgery or areas of inflammation? Yes No If yes, describe. Do you have sensitive skin? Yes No If yes, describe. Do you have any known allergies to oils, lotions or ointments? Yes No If yes, list any known allergies to oils, lotions or ointments. Are you currently pregnant? Yes No If yes, which stage? List any medications you are currently taking. HEALTH HISTORY(Check all that apply) Musculoskeletal Bone or Joint Disease Arthritis/Gout Lupus Migraines/Headaches Tendonitis/Bursitis Jaw Pain (TMJ) Spinal Problems Osteoporosis Respiratory Breathing Difficulty/Asthma Allergies (specify below) Emphysema Sinus Problems Reproductive Prostate Ovarian/Menstrual Problems Digestive Irritable Bowel Syndrome Colitis Ulcers Bladder/Kidney Ailment Crohn's Disease Circulatory Heart Condition Blood Clots Lymphedema Phlebitis/Varicose Veins High/Low Blood Pressure Thrombosis/Embolism Nervous System Shingles Pinched Nerve Paralysis Parkinson's Disease Numbness/Tingling Chronic Pain Multiple Sclerosis Neuropathy Skin Rashes Athlete's Foot Cosmetic Surgery Herpes/Cold Sores Psychological Anxiety/Stress Syndrome Depression Other Cancer/Tumors Drug/Alcohol/Tobacco Use Dentures Diabetes Contact Lenses Hearing Aids Any other medical condition(s) not listed: Please use this space to explain any of the conditions that you may have marked above or for any additional comments and/or questions/concerns you would like to discuss: MEMBER AGREEMENT AND HEALTH RELEASE FORM MEMBER AGREEMENT I understand and agree with the following: * It is my choice to receive Massage Therapy. I am aware of the benefits and risks of massage. I have consulted my Primary Physician and give my consent for treatments. I understand that there is no implied or stated guarantee of success, effectiveness of individual techniques or series of appointments. I acknowledge that Massage Therapy is not a substitute for medical care, medical examination or diagnosis. To the best of my ability, I have stated all medical conditions that I am aware of and will inform my Massage Therapist of any changes in my health status. RELEASE OF MEDICAL RECORDS I understand and agree with the following: * I authorize the release of my medical records or other health care information from Abide In Me Therapeutic Massage Services, including; intake forms, chart notes, reports, correspondences, billing statements, and other written information, to my healthcare providers, in order to help maintain and provide a safe and effective health care plan. CONTRACT FOR CARE I understand and agree with the following: * I will participate fully as a member of my wellness team. I will make sound choices regarding my sessions' plan based upon the information provided by my Massage Therapist. I agree to participate in my own self-care programs and adhere to the plan we select. I agree to communicate with my practitioner any time I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of his or her skills and knowledge. I authorize and direct payment to my Massage Therapist, Abide In Me Therapeutic Massage Services, for services billed.