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                                                                                            Transformational Healing

                                                                                 Client Intake Form


 

Name: ­­­­­­­­­­­­________________________________________________                    Phone:_________________________________________

 

Address:_______________________________________________________________________________________________________

 

Email:__________________________________________________________________________________________________________

 

YES NO   Have you ever had a professional massage or bodywork session? ____________________________

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YES NO   Are you presently under the care of a physician, chiropractor or other health care professional? If YES, please explain: ________________________________________________________________

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YES NO   In the past 2 years have you had any surgery, broken any bones, or had any injuries treated by a medical professional? If YES, please explain: __________________________________________________

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YES NO   Are you presently taking any herbs, prescription medication or over the counter      medication? If YES, please explain: __________________________________________________________________

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YES NO   Do you have any long term (chronic) problems such as allergies, low back pain, diabetes, frequent headaches, etc? If YES, please explain: ___________________________________________________

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YES NO   Are you oversensitive to touch or pressure in any area of the body? If YES, where: ________

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YES NO   Is there any other general or medical information that the practitioner should know before you receive a session today? If YES, please explain: _______________________________________________

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YES NO   Do you have: nut allergies or aversion to essential oils? If YES, please explain which one(s):

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Informed Consent/ Limits of Liability

I hereby request and consent to the massage, bodywork, and any other supportive therapies on me (or client named below whom I am legally responsible for) by the Practitioner who is legally licensed to perform such procedures (NVMT 7133).  I have had an opportunity to discuss with the practitioner the nature and purpose of today’s session and I understand that results are not guaranteed and there has been no promise to cure.  I understand and am informed that, as in the practice of any other health care modality, there are some risks associated with receiving massage and bodywork.  Certain medical conditions may increase the risk of experiencing negative side effects from massage.  These include cancer, fractured or broken bones, blood clots, burns, lesions, certain forms of osteoporosis, mystery pains, skin rashes, and infectious diseases of the skin.  If you suffer from any of these, or any other serious illness, please inform the Practitioner immediately as you may need to consult your physician before seeking massage therapy and bodywork sessions.  I further understand that there are alternative treatment options available for my massage or bodywork session today.  These treatment options include, but are not limited to, self-administered over the counter pain medications, rest, medical care, physical therapy, injections, bracing, and surgery.  I understand and have been informed that I have a right to seek alternative treatments if I have concerns as to the nature of my symptoms and treatment options.  I have read, or have had read to me, the above consent.  I have also had the opportunity to ask questions about its content, and by signing below I agree to the above named procedures.  I intend this consent form to cover the entire course of massage therapy and bodywork sessions with the practitioner for my current condition and for any future condition(s) for which I seek treatment.  It is also understood that the massage/ bodywork session I will be given is strictly non-sexual.  Should I at any time feel uncomfortable at all with any aspect of my session, I will immediately inform the therapist/practitioner so that the massage session may be adjusted to my level of comfort.  I also understand that the Massage Therapist has the right to terminate the session for any reason. 

 

Signed: _________________________________________________________        Date:___________________________________

                 (Patient or Parent/Guardian)

 

 

NOTES AND TREATMENT RECORD

 

Objective- What did the client say? _____________________________________________________________________________

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Objective- What did you observe, both thru gait analysis and palpation? __________________________________

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Assessment- What action(s) did you take and what were the results? ______________________________________

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Plan- What care plan did you suggest?  ________________________________________________________________________

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TRANSFORMATIONAL

HEALING​