Massage and Hydrotherapy Intake Form

Personal Information
Full Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Sex*

MaleFemale
Activities or hobbies of daily life: Please indicate what type of repetitive movements you may perform throughout the day (e.g., bending over, sitting for long periods of time, etc.)
Occupation:
Shoe Size (this helps us to know what size shower shoe you will need):
Emergency Contact*

First NameLast NameContact Relationship
Emergency Contact Phone*

Area CodePhone Number
How did you hear about us?
Medical Information
Primary Care Physician*

Primary Care PhysicianCityPhone
Are you taking any medication?*
If yes, please list name and use:
Are you currently pregnant?*
If yes, how far along?
Do you have any high risk factors related to your pregnancy?
Do you suffer from chronic pain?*
If yes, please explain:
What makes it better?
What makes it worse?
Please indicate any of the following that apply to you:*

DiabetesCancerKidney DysfunctionStrokeEpilespyHeadaches/MigrainesDepression and/or AnxietyJoint ReplacementArthritisHeart AttackHeart DiseaseHigh/Low Blood PressureBlood ClotsNeuropathyFibromyalgiaNumbnessSkin Condition (Psoriasis, fungal infection, etc.)Orthopedic Injury (i.e., sprains, strains, broken bones, etc.)Recent surgeryNone of the aboveOther
Explain any conditions you have marked above:
Have you had a professional massage before?*

YesNo
What pressure do you prefer?
Have you had an intentional hydrotherapy session before?*

YesNoNot sure
Do you have any allergies or sensitivities?*

YesNoNot sure
If yes, please explain:
Please indicate areas that you want the therapist to avoid during the massage (e.g., feet, buttocks, etc.)*
What are your goals for this treatment session?*
For hydrotherapy clients: We are excited to guide you through this water journey! Hydrotherapy can be an indispensable tool for maximizing your health and wellness. Here are some things you should know before your visit:
1. Allow 1 hour for your water treatment.
2. Do not eat for 2 hours prior to your appointment.
3. Hydrotherapy is more effective with direct water-to-skin contact. Please bring a bathing suit for your treatment.
4. Towels, robes, and shower shoes will be provided.
5. Refrain from wearing make-up to your treatment.
If you have any questions, comments, or concerns please feel free to give us a call at (530) 217-3870 ext. 105.
Liability Waiver

By signing below, you agree to the following:
1. I give my permission to receive massage and hydrotherapy.
2. I understand that therapeutic massage and hydrotherapy are not a substitute for traditional medical treatment or medications.
3. I understand that the therapist does not diagnose illnesses or injuries, or prescribe medications.
4. I have clearance from my physician to receive massage and hydrotherapy.
5. I understand the risks associated with massage and hydrotherapy include, but are not limited to:
  - Superficial bruising
  - Short-term muscle soreness
  - Exacerbation of undiscovered injury
  - Heat exhaustion
  - Slips/falls
6. I understand the importance of informing the therapist of all medical conditions and medications I am taking, and to let the therapist know about any changes to these. I understand that there may be additional risks based on my physical condition.
7. I understand that it is my responsibility to inform the therapist of any discomfort I may feel during the massage or hydrotherapy session so he/she may adjust accordingly.
8. I understand that I or the therapist may terminate the session at any time.
9. I have been given a chance to ask questions about the massage and/or hydrotherapy therapy session and my questions have been answered.
I therefore release Beautiful Minds Medical Inc. and the individual treatment attendant(s) or massage therapist(s) from all liability concerning injuries that may occur during the massage session.
I consent to treatment by Beautiful Minds Medical, Inc. for massage and/or hydrotherapy as provided by the professional staff of Beautiful Minds Medical, Inc.
By signing below, I agree that all information above is true*

Clear
Should be Empty:

Personal Information

Medical Information

Liability Waiver