Devin Dawson, RMT CNP CIr

Registered Massage Therapy — Initial Intake Forms

Client Information

Sections

Personal Information

Employer Information

Emergency Contact Information

Physician Contact Information

Introduction

Medical History

Please review the list of medical conditions and check those that apply to you:

Cardiovascular

Respiratory

Skin Conditions

Infectious Conditions

Digestive

Head and Neck

Neurological

Musculoskeletal

Other

Women

Present Condition

Consider the following:

  • When did symptoms start; couple days ago or six weeks ago?
  • How fast did symptoms appear; gradually or immediately?
  • Do symptoms come in waves, and how long does each wave last?
  • Where do you currently feel symptoms exactly?
  • What do your symptoms feel like, can you describe it? Burning, tingling, numb, ache?
  • What seems to make it worse? What makes it feel better?
  • What do you feel caused the problem?
  • How intense would you describe your symptoms, for example, from 0 to 10?

Funding Information

Extended Healthcare Plan Information

Only fill this information out if you wish to have our office submit Extended Healthcare Plan claims on your behalf.

Additional Information

Pain Chart

Please mark areas of pain, discomfort, or symptoms, on the body chart below:

Notes

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Scope of Practice

The practice of Massage Therapy is the assessment of the soft tissue and joints of the body and the treatment and prevention of physical dysfunction and pain of the soft tissue and joints by manipulation to develop, maintain, rehabilitate or augment physical function, or relieve pain. (Massage Therapy Act 1991)

Policies & Procedures

Assessment & Treatment

  1. Purpose: Please inform your therapist of the intended goal for the treatment whether it is to address a particular issue or complaint, or for relaxation purposes. Generally, treatment is a nice balance of focusing on important areas and relaxation.
  2. Consent: At any time, you may refuse, discontinue or modify the assessment and/or treatment for any reason, regardless of prior consent.
  3. Clothing: Prior to any assessment and/or treatment, you will have the opportunity to undress privately to your level of comfort, leaving on any article of clothing you wish. During the treatment, you will be covered by top sheets and only areas being worked on will be uncovered and securely draped. Should you choose to leave clothing on, it is possible to perform the assessment and/or treatment over clothing if you wish.
  4. Comfort: During the treatment, please do not hesitate to let your therapist know about your pressure preferences. The therapist will periodically check with you to ensure the pressure being applied is within your level of tolerance and comfort.
  5. Risk: On rare occasion, you may experience discomfort, soreness or a mild headache for a short period of time after a treatment. Should this happen, please inform your therapist so that appropriate suggestions can be given, and adjustments can be made for your next appointment.
  6. History: Please ensure that you provide accurate and complete information regarding your health history, including diagnosed medical conditions and current medications, as these may affect your treatment. Your safety is a priority for your therapist.

Practice Policies

  1. Privacy: Your personal information and discussions that happen within the massage therapy treatment shall be kept strictly confidential and will only be shared with your prior consent or as required by law.
  2. Cancellation: If the event you are unable to keep your scheduled appointment, please provide a minimum of 24 hours notice prior to your appointment time, otherwise a cancellation fee may apply.
  3. Timing: Promptness is expected for all appointments. In the event of lateness, the massage treatment may be cut short to respect other appointment times. Fees will be maintained as per schedule.
  4. Payment: Fees are due prior to departure on the day of treatment, after services have been rendered, unless otherwise noted. Subsequent appointments will not be possible until all due payment has been received.
  5. Insurance: We offer direct billing to most extended health plans. Please make sure to bring your extended health plan member card or phone app identification with you. Photocopies of your card may be taken and stored in your file for convenience. Please note that some plans require a doctor prescription for massage therapy, and it is highly recommended you check with your plan provider before your appointment.

Consent for Sensitive Areas

There are certain sensitive areas of the body that may require assessment and/or treatment, where your verbal or written consent is required.

These areas include:

  • Breast tissue (I do not work on this area however),
  • Chest wall musculature,
  • Gluteal (buttocks) musculature, and
  • Inner thigh(s)

Should your therapist need to assess and/or treat one or more of these areas, the following will be discussed with you:

  • the nature of the assessment and/or treatment including the reason(s) for the assessment and/or treatment of the above areas, positioning, and the draping methods to be used,
  • the expected effects of the assessment and/or treatment,
  • alternative methods to working with the above areas, as well as the consequences of not receiving treatment.

At any time, you may instruct your therapist to stop or alter the assessment and/or treatment of the above areas. Your comfort is a top priority, and therefore you are always welcome to ask questions during your appointment.

Agreement

By entering my name into the field below and submitting this form, I confirm that all the information provided on this form is correct, to the best of my knowledge, and I agree to inform my therapist/practitioner of any changes to this information. I understand the information provided will be kept confidential and will only be disclosed with my prior consent or as required by law.

I confirm that I have read, understand, and agree to the terms, conditions and procedures set out in the following documents:

  • Scope of Practice (Massage Therapy)
  • Policies & Procedures
  • Consent for Sensitive Areas

If you wish to have a copy of this document and the information you've provided, please enter your email address below before you submit the form: