Massage Therapy Intake Form
There is a lot of variation in what clients get massages for. You might be post surgery (breast cancer, etc.), be looking for general health maintenance, have very specific performance goals, be preparing for a race or recovering, or just love to get a massage and want the relaxation benefit. In any case, let's help you get better!
Begin
 
Personal Information

 
First Name *

 
Last Name *

 
Gender *


 
Are you pregnant?

     
 
Birthday *

 
What is your phone number?

So we can call to discuss details further or to schedule a session.
 
We're excited you've found us. How did you hear about PerformanceGaines? *


 
Name of Therapist *


 
If you engage in one on one or group training, what's the name of the trainer you work with the most?

 
General Medical History

 
Are you currently taking any medication (blood pressure, epilepsy, diabetes)? *

     
 
Please note the medication(s) you are taking and the reason for each.

 
Please list any allergies or skin sensitivities that you know of. *

 
Please share any injuries or surgeries you've had in the past 10 years. *

We are interested in all minor or major injuries including tears, strains, fracture, or sprains and if you had any surgical procedure.
 
Have you worked with a massage therapist before? *

     
 
If there's something you want to flag for us about that experience, whether positive or negative, let us know so we can better work with you.

 
Current Complaint/Injury

 
Please share the location(s) of your complaint. *











 
Is this the first episode of this complaint/injury? If multiple, please explain (when it began, frequency of instances, intensity). *

 
What makes it worse? Or better? *

 
Have you seen another health care professional? If you have a diagnosis, what is it? *

 
Please share any other previous/current treatment(s) for this complaint. *

 
Do you have any difficulty lying on your front, back, or side? *

     
 
Please explain the details around your difficulty lying down.

 
Does your current musculoskeletal complaint/injury affect your sleep? If so, please explain.

 
Releases

 
Hazard Release *

I, {{answer_37597911}} {{answer_37597912}}, have been informed of, understand and am aware that strength, flexibility and aerobic exercise, including the use of weights and other equipment, are potentially hazardous activities. I also have been informed of, understand and am aware that fitness activities involve a risk of injury, including a remote risk of death or serious disability, and that I am voluntarily participating in these activities and using weights and equipment with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to, and do, expressly assume and accept any and all risks of injury or death arising from or related to all such activities and use of weights and equipment.
     
 
Participation Release *

I, {{answer_37597911}} {{answer_37597912}}, in consideration of being allowed to participate in the personal fitness training activities and programs of PerformanceGaines LLC and to use the facilities, weights, equipment and services located at PerformanceGaines, in addition to the payment of any fee or charge, do hereby forever waive, release and discharge PerformanceGaines LLC, and their respective officers, agents, owners, members, trainers, employees, representatives, executors and all others acting with, for, or on their behalf (collectively, “Trainers”) from any and all claims or liabilities for injuries or damages to my person and/or property, arising out of or connected with my participation in any activities, programs or services offered by Trainers or the use of any weights or equipment at various sites, including but not limited to my home, provided by and/or recommended by Trainers.
     
 
Physical Release *

I, {{answer_37597911}} {{answer_37597912}}, do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my full participation in these activities, including the use of weights or equipment. I do hereby acknowledge that I have been informed of the need for a physician’s approval for my participation in the exercise activities, programs and use of weights and exercise equipment. I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise and use of weights and exercise equipment. I acknowledge that either I have had a physical examination and have been given my physician’s permission to participate or I have decided to participate in the exercise activities, programs and use of weights and equipment without the approval of my physician and do hereby assume all responsibility for my participation in said activities, programs and use of weights and equipment.
     
 
Non-Medical Release *

I, {{answer_37597911}} {{answer_37597912}}, understand that Trainers providing and maintaining an exercise/fitness program for me does not constitute an acknowledgment, representation or indication of my physiological well-being or a medical opinion relating thereto.
     
 
Photographic & Media Consent Form

I, {{answer_37597911}} {{answer_37597912}}, hereby consent to the collection and use of my personal images by photography or video recording.   I acknowledge these may be used on the PerformanceGaines website, in newsletters and publications, as well as distributed to members. 

I understand that no personal information, such as names, will be used in any publications unless express consent is given.   I give this consent voluntarily.    I also understand that my consent can be withdrawn at anytime in writing to Christopher Gaines at chris@performancegaines.com.  I give this consent voluntarily.
     
 
Release of Information

 
Authorization to Release/Exchange Information

I, {{answer_37597911}} {{answer_37597912}} (hereinafter "Client"), hereby authorize {{answer_37598585}}, (“Provider”) to disclose/exchange manual therapy treatment information and records obtained in the course of my physiotherapy treatment, including, but not limited to therapist’s diagnosis of me, to  {{answer_38449863}}. 
I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of this authorization must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider has taken action in reliance upon it. And, I also understand that such revocation must be in writing and received by Provider to be effective. 
Provider shall not condition treatment upon Client signing this authorization and Client has the right to refuse to sign this form. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule, although applicable California law may protect such information. 
This authorization shall remain valid for a period of one year.
     
 
As a client, we want you to have a great experience and relationship with your therapist, from day one. Is there any information you want us to know that will help us better serve you?

Thank you for completing the intake form!
We'll be in touch shortly to schedule or confirm your massage.
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