BFit Sports/Therapeutic Massage - Client Intake FormName(Required)Date of Birth(Required)Address(Required)Email(Required)Phone(Required)OccupationHave you received massage therapy before? Yes NoWhat are your goals/needs for massage?Current HealthDescribe any regular exercise and/or sports you participate in.Describe any repetitive movements you perform in work, sports, or hobbies.Describe any long periods of sitting you have at work, home, or driving.Describe any stress in work, family, or other aspects of your life.Describe any tension, stiffness, discomfort, or pain you experience.Describe any recent injuries, surgeries, or areas of inflammation.Do you have sensitive skin? Yes NoPlease list any and all allergies (including oils, lotions, ointments, and other).Please list any and all medications you are currently taking.Please list any and all accidents, surgeries, or major illnesses you have experienced (include date and description)Physician's Name(Required)Physician's Phone Number(Required)Health HistoryMusculoskeletal Bone or Joint Disease Tendonitis/Bursitis Arthritis/Gout Jaw Pain (TMJ) Lupus Spinal Problems Migraines/Headaches Osteoporosis(Check all that apply)Circulatory Heart Condition Phlebitis/Varicose Veins Blood Clots High/Low Blood Pressure Lymphedema Thrombosis/Embolism(Check all that apply)Respiratory Breathing/Asthma Emphysema Allergies Sinus Problems(Check all that apply)Nervous System Shingles Numbness/Tingling Pinched Nerve Chronic Pain Paralysis Multiple Sclerosis Parkinson's Disease(Check all that apply)Reproductive Pregnant, Trimester Overian/Menstrual Prostate(Check all that apply)Skin Allergies Rashes Cosmetic Surgery Athlete's Foot Herpes/Cold Sores(Check all that apply)Psychological Anxiety/Stress Depression(Check all that apply)Other Cancer/Tumors Diabetes Drug/Alcohol Use Contact Lenses Dentures Hearing Aids(Check all that apply)Please list any and all other medical conditions.Please describe any conditions marked.Consent for Massage Therapy (Please sign name in box below)(Required)I understand that massage is for the purposes of (stress reduction, pain reduction, relief from muscle tension, increasing circulation, or specific reasons stated here). I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy. I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any conditions I may have. I have stated all my known physical conditions and medications, and I will keep the massage therapist updated on any changes.Today's Date(Required)
