Fitness Essentials

Download the PDF Version of the Intake Form
Client Contact Information Please complete all the responses to the best of your knowledge. (All information is strictly confidential)
* Indicates a required field

Name (Last, First, MI)
Age
Sex
Address (Street, City, ST, Zip)
Email
Home Phone
Cell Phone
Occupation
Emergency Contact Name
Emergency Contact Phone
Referred By
Have you had massages, bodywork/treatments before? Yes No
Do you wear contact lenses? Yes No
Do you wear dentures? Yes No
Are you currently under a physician's care? Yes No
Are you taking any blood-clotting medication? Yes No
Are you taking any blood-thinning medication? Yes No
Are you taking any sensation-altering medication? Yes No
Do you have a tendency to bruise easily? Yes No
Have you recently been exposed to a communicable disease? Yes No
Do you have any recent injuries? Yes No
If so, please explain:
Please list the areas you wish to focus on
Please list the areas you wish not to have focused on
Please check any of the following medical conditions/symptoms that you have experienced in the last year








Heart Disease
High Blood Pressure
Hospitalization
Hepatitis
Carpel Tunnel
Sciatica
Stroke
Varicose Veins








Surgery
Herpes Simplex
Whiplash
Asthma
Angina
Phlebitis/Thrombosis
Fibromyalgia
Disc Problems






Immunity Related Disorder
Insomnia
Hypertension
Migraines
Contagious Disease
Pregnancy
Repetitive Strain Injury
Other: Please describe



Specific Medical Conditions
For your safety, our therapists must be aware of all medical conditions for which you have been diagnosed. Massages, bodywork/treatments may impact your health.
Arthritis Yes No
Please describe
Cancer or Tumors Yes No
Please describe
Cardiovascular Disease Yes No
Please list any of the following that apply to you: Anemia, Angina, Athersclerosis, Hemophilia, Congestive Heart Failure, Heart Attack, Heart Murmur, Hypertension, High Blood Pressure, Varicose or Spider Veins, Other
Diabetes Yes No
Please describe
Kidney or Liver Disease Yes No
Please describe
Respiratory or Lung Condition Yes No
Please describe
Skin Conditions Yes No
Please list any of the following that apply to you: Acne, Abrasions/Cuts, Birthmarks/Moles, Warts, Bruises, Dermatitis, Eczema, Herpes, Hives, Poison Ivy/Oak/Sumac, Psoriasis, Skin Tags, Sunburn, Other
Injuries Yes No
Please describe



Please read and sign
I verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety purposes and will be kept strictly confidential, except that such information may be used by Fitness Essentials, LLC for statistical analysis or scientific purposes.

I hereby give my consent to receive massage services and/or other bodywork or treatment (the “Services”) from Fitness Essentials, LLC, and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such Services are my sole responsibility. I acknowledge that my receipt of the Services from Fitness Essentials, LLC may result in bodily injury to me or my death. My decision to receive Services from Fitness Essentials, LLC is voluntary, and I know of, understand and assume any and all the risks associated therewith.

In exchange for receiving Services from Fitness Essentials, LLC, I, for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold harmless Fitness Essentials, LLC, its members, officers, employees and agents from any and all liability for any and all injuries, including death, damages or claims relating to or resulting from my receipt of the Services, now or in the future, foreseen or unforeseen. Further, I will indemnify and hold Fitness Essentials, LLC, its members, officers, agents and employees, harmless from and against any and all claims, rights, damages, liabilities, losses, costs and expenses (including reasonable attorneys’ fees) arising from or in connection with any injuries to other persons or damage to property caused by or attributed to me.

I acknowledge that I have read, and understand, the release and indemnification provisions set forth in the preceding paragraph, and agree to such terms.

Client Signature*
Date*



Massage Client Waiver Form
Please take a moment to read and initial the following information:
I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.*

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.*

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.*

I affirm that I have notified my therapist of all known medical conditions and injuries.*

I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.*

I understand that massage is entirely therapeutic and non-sexual in nature.*

By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.*

I have received the policy statement, and have read and agree to the policies therein.*
Client Name*
Client Signature*
Date*
Therapist Signature




Information and Suggestions
  • Prior to your massage, please remove contact lenses and all jewelry. Pull long hair back with aclip or band.
  • In general, massage is given while you are unclothed. However, you may choose to wearundergarments or a swimsuit. You will be covered with a top sheet throughout your session. This is your massage and you should be as comfortable as possible.
  • Feel free to ask your therapist any questions before, during, or after the session. Your therapist is a highly trained professional and will be happy to make you feel informed and comfortable.

Please be aware of our 24 hour cancellation policy.

Fitness Essentials, LLC
317 South Dallas Avenue
Pittsburgh, PA 15208


Contact Us
(p) 412.519.8471
(e) bfitness2@gmail


Our Locations
The Pittsburgh Athletic Association - Personal Training
The Pittsburgh Golf Club - Personal Training
In-Home - Personal Training

 
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