New Patient Form All new patients must fill out this form prior to their first appointment Massage Patient Form Massage Patient Intake Form Patient Name * First Name Last Name Phone * (###) ### #### Email * Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation * Emergency Contact Emergency Contact Name * First Name Last Name Emergency Phone * (###) ### #### Relation to Patient * Additional Info Have you ever experienced a massage before? * Yes No What is the main reason for your massage? * Why did you choose Under Pressure Massage? * Have you ever received massage therapy? * Yes No If yes, what type of therapy? Deep Tissue Relaxation Other Please list all of your current medications * Are you currently pregnant? * Yes No If yes, how far along is your pregnancy? What is the due date for your child? MM DD YYYY Where are you experiencing pain? * Neck Jaw Shoulders Pecs (Chest) Upper Back Middle Back Lower Back Glutes Hamstrings (Back of Thighs) Quads (Front of Thighs) Calves Feet Arms Forearms Hands Other If other, describe your pain here How severe is your pain on a scale of 1-10? * 1 2 3 4 5 6 7 8 9 10 Have you suffered any of the following injuries? Accident Whiplash Broken Bones Sprains / Strains Heart Attack Stroke Other Please provide details about your injuries: Do you currently have cancer or have had cancer in the past? * Yes No If yes, please explain what type of cancer Do you currently have any of these conditions? Headaches Joint Aches Lack of Range of Motion Abdominal Pain Infection Nervous Tension Arthritis or Gout Scoliosis Fibromyalgia Carpal Tunnel Diabetes Blood Clots Varicose Veins High Blood Pressure Colitis AIDS / HIV Other Please provide any additional information about your current conditions Have you ever experienced a Mastectomy or Breast Augmentation? * Yes No If yes, please explain Do you have any of the following today? Sunburn Severe Pain Inflammation Headache Open cuts, bruises or burns Irritated skin rash Cold / Flu / Covid Do you have any skin allergies? * Please read the following and check each box to acknowledge our policies I understand that this massage is not a replacement for medical care and that no diagnosis will be made. It is recommended that I see a physician for any physical ailment that I may have. * I understand I understand that massage therapists do not prescribe medical treatments or pharmaceuticals, and does not preform any spinal adjustments. * I understand I am aware that if I have any serious medical diagnosis, I must provide a physician's written consent prior to services. * I understand I understand that draping will be used on ALL areas not being treated. If the client or therapist is uncomfortable for any reason, the clients or therapist may ask to end the session, and the session will be ended. * I understand I understand that I will be responsible for any payment of $40 for any unapproved cancellations * I understand I COMPLETLY UNDERSTAND THAT UNDER PRESSURE MASSAGE IS A ZERO-TOLERANCE ESTABLISHMENT. IN UNDERSTANDING THIS, I WILL NOT MAKE JOKES, INNUENDOS, OR INAPPROPRIATE TOUCHING, SEXUAL REQUESTS OR SOLICITATIONS OF ANY KIND. IF I DO SO, I UNDERSTAND THE SESSION WILL BE TERMINATED AND MY INFORMATION WILL BE HANDED OVER TO POLICE * I understand Thank you for submitting the new patient intake form! We will get back to you for scheduling ASAP. Physical Therapy Registration
