Relax & Be Well general intake form

Relax & Be Well, LLC

Therapeutic Massage and Wellness Coaching

About
Contact
Health Intake Form
Pregnancy Form
Oncology Form
Pediatric Form (0-17)
COVID-19 (Coronavirus) Liability Release Form
New COVID-19 Massage Protocols

About
Contact
Health Intake Form
Pregnancy Form
Oncology Form
Pediatric Form (0-17)
COVID-19 (Coronavirus) Liability Release Form
New COVID-19 Massage Protocols

Name*

Address*

Birth Date*

Primary Phone*

Secondary Phone

Email Address*

Preferred Method of Contact (Please choose One)*

EmailText MessagePhone Call

Occupation *

Referred By

Emergency Contact Name, Relationship to Client & Phone*

Primary Physician, Clinic Name & Phone Number

How would you rate your overall health?

ExcellentGoodFairPoor

Have you ever received a professional massage?*

YesNo

Reason for seeking massage therapy*

In order to better address your goals, please state your specific concerns and approximate date of onset*

What is your exercise level?*

Do you perform any repetitive movements in your work, hobbies, sports, ect.?*

YesNo

If yes, please describe

Check all activities that apply to you*

SittingStandingComputer WorkLight LaborHeavy Labor

Do you have stress in your work, family, or other aspects of your life?*

YesNo

If yes, please describe

Have you had any recent accidents, injuries or surgeries (in the past 6 months)?*

YesNo

If yes, please describe

Do you have any allergies/sensitivities to oils, lotions or scents? *

YesNo

If yes, please describe

Please list any current medications (prescription and over the counter) or supplements you take and what they are treating. **LIST NONE, IF YOU DON'T TAKE ANYTHING.***

Do you have experience with Essential oils?

YesNo

Health History

Please check ALL that apply

Head/Neck*

headaches/migrainesjaw pain (TMJ)ringing in earsvision problemsvertigo/dizzinesshearing lossvision lossNONE APPLY

Musculoskeletal System*

bone or joint diseasespinal problemsmuscle tensiontendonitisbursitisheadaches/migrainesbroken bonesarthritis/goutosteoporosispins/plates/screws/wiresback painartificial joint(s)NONE APPLY

Circulatory System*

heart conditionthrombosis/embolismblood clotslymphedemastrokeanemialow blood pressurehigh blood pressurevaricose veinscirculatory problemsHIV/AIDSheart attackNONE APPLY

Nervous System*

tingling/numbnesssensory loss/changeParkinson's diseasepinched nervefibromyalgiaepilepsy/seizureschronic painparalysisM.S.peripheral neuropathysciatica/piriformis syndromeNONE APPLY

Auto-Immune*

lupusceliac diseasetype 1 diabetespsoriasisGuillain-Barre SyndromeAnkylosing SpondylitisGrave's diseaseHashimoto'salopeciaSjogren's syndromevasculitisinflammatory bowel disease (IBD) (Ulcerative Colitis or Crohn's disease)NONE APPLY

Respiratory System *

breathing difficulties/shortness of breathasthmachronic coughbronchitisemphysemasinusitisfrequent coldsCOVID-19NONE APPLY

Skin *

athlete's footplantar's wartscuts or soresshinglesrashherpes/cold soresacneeczemaimpetigoringwormrosaceavitiligodry skinmelasmaNONE APPLY

Digestive System*

irritable bowel syndromeulcersbladder/kidney ailmentconstipationdiarrheaNONE APPLY

Psychological*

anxietystressdepressionPost Traumatic Stress Disorder (PTSD)bipolar disorderdementiaAttention Deficit/Hyperactivity Disorder (ADHD)schizophreniaObsessive Compulsive Disorder (OCD)Autism Spectrum Disorder (ASD)NONE APPLY

Other*

pacemakercontact lensescancer/tumors (if yes, please fill out additional form)denturespregnant (if yes, please fill out additional form)hearing aidsdrug usealcohol usetobacco useport (for IV use)NONE APPLY

Any other medical conditions not listed above

Waiver of Liability and Consent to have Massage*

I agree to submitting intake forms online and waive all claims.I agree to hold harmless Relax & Be Well, LLC, of all claims, including Andree Strauss, her spouse, her heirs, her property and associations.I understand that my information will not be shared with anyone outside of Relax & Be Well, LLC without my written consent.I understand that if I have a specific medical condition or specific symptoms, massage may be contraindicated. A referral from my primary care provider may then be required prior to my massage session. If I experience any pain or discomfort during my massage, I will inform the practitioner immediately.I understand that the massage therapist cannot diagnose any medical conditions, but they can recommend seeing a medical doctor or medical specialist with any concerns.I understand that if I choose to have a cupping session (alone or added to massage) that there may be visible marks left on my body, that may last up to a couple of weeks.I have answered the above information to the best of my knowledge and will let the practitioner know if anything changes with my health history.

Cancellation Policy*

I understand that I will be charged 50% of my scheduled service fee if I cancel my appointment less than 24 hours before my scheduled time, with the exception of illness, emergency or inclement weather.I understand I will NOT be charged if I need to cancel within 24 hours due to COVID-19 symptoms in myself or another member of my household.

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Thank you for submitting intake form. See you at your first appointment. If you need to schedule your first appointment Click BOOK NOW BUTTON

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