Ace of Cups Massage Intake Form Legal Name* First Last Pronouns Prefered Name PhoneDate of Birth* MM slash DD slash YYYY Email* Emergency Contact* First Last Emergency Contact Phone*Doctor (if applicable) First Last Doctor Contact PhoneOccupation Is this your first massage?* YES NO What services are you receiving today?* Are you experiencing any pain or symptoms? Describe what you believe may be causing itDo you currently have any emotional or physical stressors in your life?Do you regularly exercise or play sports?What is your goal for today’s session?What pressure do you generally like during a massage session?*LightMediumFirmDeepHow do you prefer the temperature of your treatment room?*CoolWarmVery WarmHealth History (please check all that apply) Musculoskeletal Bone or joint disease Tendonitis/Bursitis Arthritis/Gout Jaw Pain (TMJ) Lupus Spinal Problems Migraines/Headaches Osteoporosis Nervous System Shingles Numbness/Tingling Pinched Nerve Chronic Pain Paralysis Multiple Sclerosis Parkinson’s Disease Digestive Irritable Bowel Syndrome Bladder/Kidney Ailment Colitis Crohn’s Disease Ulcers Circulatory Heart Condition Phlebitis/Varicose Veins Blood Clots High/Low Blood Pressure Lymphedema Thrombosis/Embolism Reproductive Pregnant Ovarian/Menstrual Problems Prostate Psychological Anxiety/Stress Syndrome Depression Respiratory Breathing Difficulty/Asthma Emphysema Allergies Sinus Problems Skin Allergies Rashes Cosmetic Surgery Athlete’s Foot Herpes/Cold Sores Other Cancer/Tumors Diabetes Drug/Alcohol/Tobacco Use Contact Lenses Herpes/Cold Sores Dentures Hearing Aids Please explain any of the conditions marked aboveAre there any other conditions not listed? Are there any daily activities you can no longer perform because of your current condition?Please list all previous injuries and surgeries:Please list any current medications:Are there any areas you would like for us to avoid? COVID-19 Health Information & Informed ConsentThis document contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully and let me know if you have any questions.Client Name* First Last Date* MM slash DD slash YYYY 1. Have you had a fever in the last 24 hours of 100°F or above?* YES NO 2. Do you now, or have you recently had, any respiratory or flu symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)?* YES NO 3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?* YES NO 4. Have you traveled anywhere outside of the state in the last two weeks?* YES NO Location* 5. Have you had a new loss of sense of taste or smell?* YES NO The following questions are specific to a new aspect of COVID-19 involving blood coagulation6. Can you exercise to get your heart rate and respiratory rate up without any problem?* YES NO 7. Have you had a new onset of muscle aches and pain since the emergence of the virus?* YES NO 8. Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?* YES NO Are you under the age of 17? If yes, you must have the written consent of your parent or guardian to participate in our massage therapy services. The massage therapist will not perform a breast massage on female clients without the written consent of the client prior to the massage session. Draping will be used during the massage session unless otherwise agreed to by both client and therapist. If the client is uncomfortable for any reason, the client may ask to end the massage session, and the session will be ended. Massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I may have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals, and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis, I must provide a physician’s written consent prior to service. Consent for Treatment To proceed with receiving care, I confirm and understand the following I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult. I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care. I have been offered a copy of this consent form. I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.Consent* I agree to the this policyBy signing this form, I consent to receive massage therapy as stated by the Texas Department of Licensing and Regulation. I understand that I can revoke consent for this and any future massage at any point without repercussions by any individual or governing entity. Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
