Massage Intake Form – diVINE SPA Team

Name*

First Last

DOB*

Phone*

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

How did you hear about us?*

TripAdvisor
Yelp
Google Search
Someone Referred Me
I Received a Gift Certificate

Referred By Name*

Name

Tell us who should we send a thank you note.

Emergency contact name:

First Last

Emergency contact phone

Physician contact name:

First Last

Only if needed by therapist

Physician contact phone

Only if needed by therapist

Permission to contact*

I GIVE MY PERMISSION TO CONTACT

Occupation

Gender*

Male
Female

Enter your wedding date If you would like us to remind your husband of your wedding anniversary with a spa treatment.

Enter your wedding date if you want to receive special offer from diVINE SPA.

Wedding Date

Are you pregnant?*

YES
NO

Pregnancy Release Form

There are several observed or identified potential benefits to massage therapy during pregnancy including:

• Relieves muscular tension, especially in the lower back, upper back, shoulders and neck

• Reduces stress on weight-bearing joints

• Enhances body awareness for better posture and less discomfort

• Assists with body mechanics and movement during structural change

• Supports birth process by relaxing muscles involved in labor an birth

• Eases anxiety and stress during time of transition

• Provides emotional support and nurturance

Prenatal Massage Therapy Contraindications

Performing massage therapy during pregnancy is contraindicated for women experiencing any of the following symptoms/signs:

• Bloody discharge

• Continual abdominal pains

• Sudden gush or leakage of amniotic fluid

• Sudden, rapid weight gain

• Increased blood pressure

• Protein or sugar in urine

• Severe back pain that does not subside with the change in position

• Visual disturbances

• Severe nausea and /or vomiting

• Severe headaches

• Excessive hunger and thirst

• Increased urination in the second trimester

• Fever

• Diarrhea

• Excessive swelling in our arms or legs

• A decrease in fetal movement over a twenty-four hour period

Some additional conditions that contraindicate massage therapy are any phlebitis, thrombosis, or suspected clotting conditions, any kidney, liver or spleen compromise or infection. Local massage on areas with severe varicose veins and swelling are avoided due to clotting risk.

Prenatal High Risk Pregnancies

It is a strict policy of diVINE SPA to require a signed doctor's release form in order for the client to receive massage therapy services if a client has a high risk pregnancy. High risk pregnancies include, but are not limited to:

1.) Early labor, miscarriage threat, placental or cervical dysfunction;

2.) Gestational Edema Proteinuria Hypertension (GEPH);

3.) Preeclampsia;

4.) Gestational Diabetes;

5.) Pre-existing cardiac, renal, connective tissues or liver disorders/diseases;

6.) Fetal genetic disorders;

7.) Complications in previous pregnancies;

8.) Three or more miscarriages

I have received and read the written information about the benefits and possible contraindications of massage therapy during pregnancy. I understand the information and confirm that:

• I have not experienced any of the complications listed on the sheet below;

• I have not experienced any of the conditions listed, which would make it unwise to have

massage therapy;

• I am experiencing a low-risk pregnancy;

• I am receiving medical care including regular check-ups throughout my pregnancy.

I understand that I will be receiving massage therapy as a form of adjunctive health care only and that this therapy is not intended to replace appropriate medical care.

Having been fully advised of the risks, contraindications, and complications to massage therapy during pregnancy, I have decided to participate in the therapy. Accordingly, I do forever release the practitioners and their insurers, and their respective officers, directors, stockholders, successors, employees and agents from all liability of any nature whatsoever, whether past, present, or future for injury or damage which may occur to myself or my family as a result of my receiving massage therapy during this childbearing year.

I further agree to hold harmless and defend the practitioner of and from all actions, claims, or other legal or administrative action that has arisen or may arise directly from my and my child's participation in this therapy.

I consent to the pre-natal massage therapy and treatment*

I AGREE TO THE PREGNANCY RELEASE FORM

Please read the consent form

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.

Have you ever experienced a professional massage or bodywork session?*

YES
NO

I Received My Last Massage*

A Week Ago
Less Than 3 Weeks Ago
Less Than 1 Month Ago
In the Last 3 Months
In the Last 6 Months
In the Last Year
More Than a Year Ago

What are your massage or bodywork goals?*

What Kind of Pressure do you prefer?*

LIGHT
MEDIUM
FIRM

If you answer "yes" to any of the following questions, please explain as clearly as possible

Do you frequently suffer from stress?*

YES
NO

Do you have diabetes?*

YES
NO

Do you experience frequent headaches/migraine?*

YES
NO

Do you suffer from arthritis?*

YES
NO

Are you wearing contact lenses/dentures/hearing aids?*

Contact Lenses
Dentures
Hearing Aids
None

Select all that apply

Do you have cardiac or circulatory problems?*

YES
NO

Do you have high blood pressure?*

YES
NO

Do you have tension or soreness in a specific area?*

YES
NO

Tension / Soreness Location*

Are you sensitive to touch or pressure in any area?*

YES
NO

Sensitivity to Pressure Location*

Are you currently undergoing any treatment?*

YES
NO

Type of Treatment*

Are you currently taking any medications?*

YES
NO

Specify Medications*

Do you have any immune system conditions (chronic fatigue / HIV / AIDS)?*

Chronic Fatigue
HIV / AIDS
NO

Have you ever had cancer?*

YES
NO

Had cancer when?*

Currently
Previously

Type of Cancer*

Do you bruise easily?*

YES
NO

Any broken bones/injuries in the past two years?*

YES
NO

Specify Broken Bones / Injuries*

Do you suffer from back pain?*

YES
NO

Type of Back Pain*

Acute
Chronic

Back Pain Location*

Have you ever suffered a stroke?*

YES
NO

Do you have a pacemaker?*

YES
NO

Do you have numbness or stabbing pains?*

YES
NO

Numbness / Stabbing Pain Location*

Do you suffer from epilepsy or seizures?*

YES
NO

Do you have any joint replacements?*

YES
NO

Specify Joint Replacement*

Do you have osteoporosis?*

YES
NO

Do you have varicose veins?*

YES
NO

Have you ever had surgery?*

YES
NO

Specify Surgery*

Do you have any contagious diseases?*

YES
NO

Specify Contagious Diseases*

Do you have any skin allergies*

YES
NO

Are there any other medical conditions I should know about?

Please explain

I consent to massage therapy and treatment*

I AGREE TO THE MASSAGE RELEASE FORM

Please read the consent form

Massage Release Form

I have read and understood this Client Intake and Health History form in its entirety. If at any time there are changes in the information given, or in my condition, I will notify the therapist and update this form before receiving additional massage. I have stated all my known medical conditions and have answered all questions honestly. If there is any information not directly requested on this form, which would compromise my ability to safely receive massage, I am responsible for bringing that information to the therapist's attention.

The massage treatment I am requesting is for the purpose(s) of relaxation, stress reduction, relief from muscle tension or spasm, to improve range of motion, circulation, or energy.

I understand the massage therapist does not diagnose or prescribe for medical illness, disease, or other disorders and that spinal manipulation is not part of massage therapy. I further understand that massage therapy is not a substitute for medical examination or diagnosis, and that I take responsibility for consulting with my physician for any ailment or condition of concern to me. If I experience any pain or discomfort during the massage session, I will immediately communicate that to the therapist so that treatment can be adjusted accordingly.

I understand that my feedback is an essential element in my treatment. If at any time I become uncomfortable during the massage, I may bring that to the therapist's attention and request that the session be modified, temporarily suspended, or brought to an end. However, I can ask that a session be discontinued at any time, for any reason, and the therapist will honor that request.

Unless in emergency or inclement weather, I acknowledge that if I am unable to keep a schedule appointment, 24 hours notice is required or I will be charged for the time reserved.

I also understand 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.

Clients Signature*

Date*

Are you under 18 years of age?*

YES
NO

Parent or Guardian's Signature*