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(970) 609-8899
Mesa County Health Department Rating
Rated 5 out of 5
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Massage Services
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Massage FAQ’s
Pain Management
Microcurrent Therapy for Inflammation/Pain
Healy Device
Percussion Therapy
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DermaSweep MicroDermabrasion
Bio-Therapeutic Microcurrent Technology
Cosmetic Laser Treatments
Laser Hair Removal
Pricing
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Contact
home
Massage Services
Benefits of Massage
Massage FAQ’s
Pain Management
Microcurrent Therapy for Inflammation/Pain
Healy Device
Percussion Therapy
Skin Care Services
DermaSweep MicroDermabrasion
Bio-Therapeutic Microcurrent Technology
Cosmetic Laser Treatments
Laser Hair Removal
Pricing
Our Office
Hours & Scheduling
Products
Specials & Gift Certificates
Contact
Massage Intake Form
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ALL INFORMATION BELOW IS PROTECTED BY CURRENT COLORADO STATE HIPPA REGULATIONS AND WILL NOT BE SHARED WITH ANYONE WITHOUT YOUR CONSENT.
Name
*
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Phone
*
Email
*
Occupation
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May we call you to follow up on treatment results?
YES
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May we contact you about specials, "thank you" discounts for referrals, or events?
YES
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If yes, how would you like us to contact your?
Emergency Contact
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Were you referred to our office?
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By whom?
May we send them a "thank you for referring you to our office"?
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City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Have you ever had a massage before?
YES
NO
How long ago?
Primary reason for you visit today?
What results do you expect from today's visit?
Do you have an important event in the near future?
Do you have any special needs or requests?
Are you taking any medication/herbs (includes aspirin, ibuprofen, supplements)? Please list.
We want to give you the best treatment possible.
To avoid stimulating or aggravating a current condition we would like to know if you have any chronic systemic illness that we should be aware of? (e.i.: Hepatitis, Epstein Barr, etc...)
If so, have you been released by your physcian?
YES
NO
Are you currently under a physician's care for an injury/illness?
YES
NO
Do you have any allergies to medications, lotions, detergents, cleaning products, etc?
We occasionally use aromatherapy or essential oils during our treatments. Do you have any sensetivities to any scents or products that are scented?
Have you ever had any injuries or surgeries? Please list occurance and date
Occurence
Date
Please mark below a (C) for Current condition or (P) for Past condition
Headaches/migraines
Allergies
Neck Pain
Back Pain
Spinal column disorders
Sprains/strains
Muscle/joint pain
Muscle/bone injuries
Arthritis/tendonitis
Number/tingling
Heart/circulatory disorders
High/Low Blood Pressure
Blood thinners
Diuretics
Chronic pain
TMJ
Varicose/spider veins
Diabetes
Clotting disorders
Cancer/tumors
Asthma or Lung Conditions
Indigestion/Heartburn/Hernia
Constipation/diarrhea
Crones disease
Thyroid problems
Anxiety/Stress
Menupause
PMS
Insomnia
Sinus Problems
Pregnancies
Vision problems or contacts
Dental bridges, braces
Birth Control
Skin Conditions
Acne
Rashes
Cold sores
Rosacea
Claustrophobia
Light sensetivity (skin or eyes)
Other medical conditions not listed:
Please list all forms and frequency of stress reduction activities, hobbies, exercise or sports participation
It is important that you drink plenty of water after a massage. Massage promotes circulation of blood, lymph and in some cases intestinal matter. Water helps clear toxins and keeps you feeling your best. It is recommended that you drink half your body weight, daily, in ounces of water. This does not mean coffee, tea, soft drinks, etc.
Please take a moment and carefully read the following information, circle relationship to client and sign where indicated.
If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to services being provided. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. Because massage/bodywork is contraindicated (should not be done) under certain medical conditions. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile.
Date
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Client, Parent or Guardian Signature
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Prove your humanity. What letter is missing? A,B,_,D,E
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