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Massage Intake Form
Client health history form for North Shore Integrated Massage LLC
66-216 Farrington Hwy. Suite 203
Waialua, HI 96791
808-285-3009
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Name
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Your answer
Phone Number and Address
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Your answer
Health History: medical conditions, injuries (past/present), illnesses, surgeries, medication, etc.
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Your answer
Describe your current condition as it applies to your goals for massage therapy (ex. musculoskeletal pain, tension, nerve pain, etc.). Include specific areas of concern.
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Your answer
Describe your daily activities. Include all activities that cause or exacerbate your condition.
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Your answer
List any preferences for massage style, level of pressure, or technique.
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Your answer
I have provided all medical information and will update the therapist of any changes. Severe and undiagnosed pain may indicate an underlying condition that should be evaluated by a physician prior to receiving massage. I understand that the effects of massage in regard to COVID-19 have not been studied, and there may be unknown risks involved. I have spoken to my physician about any concerns prior to receiving massage.
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I agree
I will immediately inform my therapist if I experience discomfort during a massage and have the right to end treatment at any time. There is a 48 hour cancellation policy. A $40 fee may be charged (at clinic’s discretion) when this policy is violated. There is no penalty for cancellations due to illness or injury. I AGREE TO CANCEL MY MASSAGE APPOINTMENT IF EXPERIENCING ANY SYMPTOMS OF ILLNESS.
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I agree
Signature (Type your name below)
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Your answer
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