Medical Intake Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Area CodePhone Number

Date of Birth*

Month/Day/Year

Your Email Address**PLEASE NOTE, you MUST Re-Enter your Email Address to submit form*

Confirmation Emailexample@example.com

NAME of Emergency Contact and their PHONE NUMBER*

PLEASE write the NAME and THE BEST contact number in CASE of an EMERGENCY.

How did you find me?*

PLEASE write the name of person/avenue that helped you.

What is your preferred method of communication, especially on short notice?*

Text MessageEmailPhone Call

Are you CURRENTLY taking medication that would cause you to bruise(ex.Blood thinners, aspirin etc) or substance that would otherwise be considered contraindicated for massage therapy or bodywork?(ex.recreational drugs, alcohol etc.)*

Answer Yes or No. If YES, PLEASE state what you're taking.

Please list ALL medications you are CURRENTLY taking.*

Name of medications and what it's prescribed for. IF NO medications are prescribed, PLEASE answer no medications.

Have you had any RECENT injury or surgery within the past 3 months?*

PLEASE answer Yes or No. If YES, PLEASE explain.

Are you allergic to essential oils?*

PLEASE answer Yes or No. If YES, PLEASE list which ones.

Have you had a professional massage before?*

PLEASE answer Yes or No.

What is the reason(s) for your visit?*

Ex. High Stress Levels, Pain Relief, Part of Wellness Plan, etc.

Is there a particular area of your body where you are experiencing tension, stiffness, pain or other discomfort?*

What area would you like to focus on in your session?

How would you rate your GENERAL health?*

ExcellentGoodFairPoor

PLEASE read carefully and check ALL that apply: IF none of these conditions apply, PLEASE check the LAST box at the bottom of this list.*

Have you had COVID-19? If YES, what was the date of your infection?*

PLEASE write YES or NO. If YES, Please write the date or approximate time.

Can you exercise to get your heart rate and respiratory rate up WITHOUT any problem? *

PLEASE answer Yes or No.

Have you had a NEW onset of muscle aches and pains since the emergence of COVID-19? *

PLEASE answer Yes or No.

Have you seen ANY NEW marks, rashes, spots bumps or other lesions on your skin?*

PLEASE answer Yes or no.

PLEASE carefully read the following:

It is my choice to receive massage therapy. I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. IF I experience any discomfort or pain during my session, I will immediately inform my therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for a medical examination, diagnosis, or treatment and that I should see a physician or another qualified medical specialist for any mental or physical ailment. I understand that massage 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 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 my therapist, Grace McDonald, LMT updated as to any changes in my medical profile and understand that there shall be no liability on my therapist's part should I fail to do so.

I understand that my personal health information will be collected via this HIPAA compliant form and that ALL information I provide WILL be kept confidential.

By signing below, I agree to release Grace McDonald, LMT and Graceful Touch Massage Therapy from any liability, and I hereby waive any damages in connection with the massage therapy and bodywork I receive to the fullest extent permitted by NY State law.

I agree that this Release/Waiver is in effect for all massage therapy/bodywork sessions and will not terminate unless requested, in writing, by either party.

Client Signature*

PLEASE make sure to sign this document. Clear

Date*

MonthDayYear

375 Bay Road, Suite 104 Queensbury, NY 12804

Medical Intake Form