Post-Op Client Intake Form

The following information will be used to help plan a safe and effective session. Please answer the questions to the best of your knowledge.

Date of Initial Visit

Have you had a professional massage before?
Yes No

Do you have any difficulty lying on your front, back, or side?
Yes No

Do you have any allergies to oils, lotions or ointments?
Yes No

Do you have sensitive skin?
Yes No

Please check if you are wearing any of the following:
contact lenses dentures hearing aides

Do you sit for long hours at a workstation or driving?
Yes No

Is there a particular area of the body where you are experiencing pain or discomfort?
Yes No

Surgery Date

Location of Surgery

Surgeon

Procedure(s)

Please identify all of the areas you would like the massage therapist to concentrate on:
Arms Legs Back Abdomen Butt Neck Shoulders

Medical History
In Order plan a massage session that is safe and effective, we need some general information about your medical history.

Are you currently under medical supervision?
Yes No

Do you see a chiropractor?
Yes No

Are you currently taking any medications?
Yes No

PLEASE CHECK ANY CONDITION BELOW THAT APPLIES TO YOU, CHECK NONE IF NONE APPLY
Contagious Skin Condition Open Sores or Wounds Easy Bruising Recent Accident or Injury Artificial Joint(s) Sprains/Strains Asthma Recent Fracture Swollen Gland(s) Allergies/Sensitivities Heart Condition High Blood Pressure Circulatory disorder Varicose Veins Phlebitis Deep Vein Thrombosis/Blood Clots Joint Disorder (Rheumatoid Arthritis/Osteoarthritis/Tendinitis) Osteoporosis Epilepsy/Seizures Headaches/Migraines Cancer Diabetes Decreased Sensation Back/Neck Problems Fibromyalgia TMJ Carpal Tunnel Syndrome Tennis Elbow NONE

Please explain any condition checked

Please identify any conditions that would be useful for your massage therapist to know in planning a safe and effective session for you.

Draping will be used during your session, the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent/legal guardian during the entire session. Informed written consent must be provided by parent/legal guardian for any client under the age of 17.

understand that the Massage(s) I receive here from CDE, Inc. are for relief, relaxation and to aid in the post surgical healing process, not for medical or therapeutic purposes. If, at any time I experience any pain or discomfort I will inform my technician immediately for my comfort and safety. I further understand that my massage(s) should not be construed as a substitute for any medical exam or procedure, I should see a medical professional for any mental or physical ailments that I am aware of and that nothing said in the course of my session should be viewed as treatment for mental or physical illnesses. Being that Post Op massages should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and have answered all the questions honestly. I also agree to keep CDE, Inc. updated as to any changes in my medical profile and understand that there shall be no liability on the part of CDE, Inc. if I fail to do so. Furthermore, I attest that I have not ingested any legal or illegal drugs or narcotics that have not been prescribed to me directly by my doctor or medical professional, before or during my sessions. I additionally accede that CDE, Inc. shall not be held accountable in any way if I have been untruthful or if I violate this agreement in any way.

Please Type your First and Last Name As Accepting/Agreeing to the avove statement and verifying that all information provided in this form submission accurate.

Please Complete Prior to your appointment

Note: This form is for New Clients & for previous Clients scheduling a New Procedure that has not been booked previously.