Pre-Appointment Intake Forms | TriCity Massage and Wellness

Due to Covid-19, we are currently not allowing use of our lobby to fill out forms. You can now pre-fill out your intake forms and send them to us prior to your appointment. For a printable version you can fill out by hand & bring with you, please email: Frontdesk.tricitymassage@gmail.com or contact us at (860)512-0433

General Health Intake for massage:

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Phone *

Email *

Emergency Contact Name & Number

Have you experienced professional massage before?

Personal Massage Experience

Please use the space above to let us know your previous experience with massage therapy, what your expectations may be, likes/dislikes, or any info. you think may be important to your massage therapist. This is not required, but it helps us create a customized session for your specific needs.

Allergies, Skin Irritants, Hypersensitivities- Please list or describe

How would you rate your general health?

Excellent
Good
Fair
Poor

Pre-existing medical conditions

Headaches/ Migraines
Vision loss/ Vision Problems
Vertigo/ Dizziness
Hearing Loss
Asthma*
Chronic Cough*
Shortness of Breath*
Sensory Loss/ Change
Sciatica
Seizures
Multiple Sclerosis
Epilepsy
Numbness/Tingling
Arthritis
Osteoporosis
Tendinitis
Jaw Pain (TMJ)
Pins/plates/wires/artificial joint*
Currently Pregnant*
Recently Given Birth/ Breastfeeding
High Blood Pressure
Low Blood Pressure
Blood Clots*
Stroke*
Heart Attack*
Poor Circulation
Phlebitis/Vericose Veins
Hemophilia
Lyme Disease
Infectious Skin Conditions
Cancer*
Diabetes
Fibromyalgia
Depression
Anxiety
Chronic Fatigue Syndrome
Other Autoimmune System Disorder(s)

* Please fill out additional information in the box below. Include dates and treatments, or any concerns & questions

Additional Medical Information

Today's Date

Signature *

By signing, you agree to the following statement: "It is my choice to receive massage therapy. I am aware of the benefits and risks of massage, and give my consent for massage. I will ask my therapist about anything I do not fully understand, and I will let them know if anything needs to be altered during my session for my comfort. I understand that there is no applied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected and saved by TriCity Massage and Wellness. I understand that all information I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. Treatments may be covered by extended healthcare plans, and HSAs. I understand that it is my responsibility to confirm the exact details of my coverage."

Message

Covid-19 form:

All clients must fill out this form prior to their next visit. If you would prefer to have a PDF file emailed to you to print & fill out by hand, please call (860)512-0433 or email Frondesk.tricitymassage@gmail.com Thank you!

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Phone *

Email *

Emergency Contact Name & Number

Have you recently traveled to any of the following states *

Alabama
Arizona
Florida
Georgia
Louisiana
Mississippi
Nevada
Nebraska
North Carolina
Puerto Rico
South Carolina
Tennessee
Texas
I have not traveled to any of these locations

These states are considered "hot spots" for covid19, you should self quarantine for 2 weeks after your trip. Please wait to come in until after you have quarantined or have been tested and received a negative test result. We apologize for the inconvenience but due to the nature of our services we are looking out for the safety of all guests and staff. Thank you for understanding. This list will be updated weekly

Have you been in places with a high infection rate within the last 2 weeks? If yes, please explain *

How would you rate your general health?

Excellent
Good
Fair
Poor

Have you been tested for COVID-19 *

Yes*
No

* If yes, please provide information in the box below:

If Yes: When was the date of your test? What type of test did you receive? What was the result of your test?

Do you have any new discomfort with exertion or exercise?

Covid-19 Specific Health Conditions *

Fever*
Chills*
Cough*
Sore Throat*
Nasal, Sinus Congestion*
Loss of Sense of Smell or Taste*
Fatigue*
Shortness of Breath*
Sudden Onset of Muscle Soreness (not related to specific activity)*
Diarrhea, digestive upset*
Rash or Skin Legions (specifically on the feet)*
Recent Development of Blood Clots***
None of the above, I have not had any of these symptoms , or have not experienced them in over 14 days*

*Please fill out additional information in the box below. Include dates and treatments, or any concerns & questions ***Blood clots are a contraindication of massage, and current information suggests they can be a side effect or symptom of covid-19 related illness. For your health and safety we may decide not to perform massage without a note from your primary care physician.

Additional Medical Information

Today's Date

Signature *

By signing, you agree to the following statement: "I understand that close contact with people increases the risk of infection from COVID-19. I am aware of the risks involved and give consent to receive massage. I also understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at TriCity Massage and Wellness tests positive for COVID-19. My contact details and health information will only be shared in the event they are relevant based on suspected exposure date and only for appropriate follow-up by the health department, as required by law."

Name

Prenatal MAssage Form

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Emergency Contact Name and Phone Number *

Medical Conditions and Symptoms *

Gestational Diabetes
History of miscarraige
Cardiac, pulmonary, liver, or renal disorders
Shortness of breath
Pitting Edema
Epilepsy or other convulsive disorders
Placenta or cervical dysfunction
Abdominal Pain
Leaking of amniotic fluid
Fever
Sudden Edema/ Swelling
Severe Headaches
Recent surgery
Preeclamsia
High blood pressure
Low blood pressure
History of High Risk Pregnancy
Hypertension
Genetic Abnormalities
Fetal Growth Retardation
Bloody Discharge
Sudden Weight Gain (other than typical weight gain associated with normal pregnancy)
Diarrhea
Decrease in Fetal Movement in Over 24 Hour Period
Severe Nausea or Vomiting
none of above

You must inform your massage therapist if you have, or have had in the past, any of the above conditions or symptoms. These may make your massage contraindicated, or your therapist may alter the massage techniques. Please provide and additional information in the box below:

Additional Information

Signature *

By signing you agree to the following statement: "Massage therapy during pregnancy has been shown to be beneficial for a number of common discomforts such as fatigue, musculoskeletal pain, sciatica, edema, and many others. However, I understand that there are a few risks associated with specific conditions that may occur during pregnancy. I have read the aforementioned conditions & symptoms which make massage therapy contraindicated during pregnancy. I will ask any questions I have and discuss my concerns with my therapist prior to my session. I have disclosed any and all high risk factors of my pregnancy. I have discussed with my prenatal health care provider any health concerns I had about receiving massage therapy. I agree that my health care provider has given me clearance to receive massage therapy. I understand the information contained on this form and confirm that (1) I am receiving medical care including regular check-ups with a licensed healthcare provider. (2) I have not experienced and conditions or complications. (3) I am not currently experiencing listed symptoms, conditions, or complications. (4) I am experiencing a low-risk pregnancy. I understand that I will be receiving massage therapy as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist, and TriCity Massage & Wellness, of any and all liability for any harm that may unintentionally occur during my treatment(s)."

Date *

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