Client Intake Forms

MASSAGE THERAPY INFORMED CONSENT
I understand that Massage Therapy provided Kathleen Benanti, RUB Therapeutic Massage or Integrated Sports Therapies is intended to enhance relaxation, reduce pain caused by muscle tension, improve circulation and offer a positive experience of touch.
I understand that massage is not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware that Massage Therapists in the State of Texas do not diagnose illness or disease, do not prescribe medications, and do not treat any disorders. Spinal manipulations are not part of the massage session.
I have informed the Massage Therapist of all my known physical conditions, medical conditions and medications, and I will keep the Massage Therapist updated on any changes. I understand that there shall be no liability on Kathleen Benanti, RUB Therapeutic Massage or Intergrated Sports Therapies if I intentionally or unintentionally withhold any pertinent medical information.
If I experience any pain or discomfort during the session, I will immediately communicate this to the Massage Therapist so the treatment can be adjusted.
I understand and agree to all of the massage clinic's policies.
I, as the patient, have read the above information and consent to therapy with the printing of my name.
  
I, as the Massage Therapist, have read the above information and consent to therapy with the printing of my name.
  
Date
  
Name
  
Address
  
City
  
State
  
Zip
  
Primary Phone
  
Employer
  
Occupation
  
Birth Date
  
Email Address
  
Emergency Contact Name and Phone Number
  
Relationship to Emergency Contact
  
Referred By
  
Primary Sport
  
Miles per Week
  
What Are Your Goals for This Session
  
Present Symptoms: What is Your Major Complaint or Condition You Want to Improve?
  
Do You Have Any of the Following Symptoms?
  
When Was the Onset of Pain?
  
What Brought it on?
  
What Activities Aggravate the Condition?
  
Is this Condition Becomming Progressively Worse?
Does This Condition Interfere with Work, Sleep and/or Your Daily Routine? Explain.
  
What Makes the Condition Feel Better?
  
What Have You Done to Get Relief?
  
Has There Been a Medical Diagnosis of Your Condition?
  
If So, By Whom? Explain.
  
Are You Currently Receiving Medical/Therapeutic Treatment?
  
List Any Medications (including Aspirin) and Nutritional Supplements That You Are Taking
  
Any Known Allergies?
  
List All Surgeries Within the Past 5 Years.