Having completed this lesson, you will be able to:

• Define the term health form.
• Describe the purpose of a health form.
• Review the components of a health form (e.g., parts and sections).
• List three pieces of information a therapist can learn from a health form (e.g., health history, prior treatments and attempts at resolving problem or conditions, medications used, etc.).
• List three situations that require a client to update a health form (e.g., recent accident, new medication or changes in treatment for a pre-existing condition, new diagnosis from a physician, annually, etc.).

A health intake form is a document the client completes before his or her first session that provides personal contact information, current health conditions, medications, past health conditions, and health related goals. The primary purpose of the form is to rule out contraindications, indicate when adaptations to treatment might be required, and help the therapist determine appropriate session objectives.

The form is designed based on the type of massage that is provided. A health intake form for a wellness session is likely to be more condensed than an intake form for a health care session. In a wellness massage the focus is most often relaxation. You need to rule out contraindications and determine client preferences to provide an enjoyable session. A health care session requires greater insight because you need to ensure that treatment goals address the client’s functional limitations (limitations to activities of daily living like lifting grandchildren, cleaning the house, working at a computer, etc.), and that improvements can be monitored to influence treatment choices in subsequent sessions. The client is asked to list and prioritize current health concerns, how these concerns impact the client’s daily activities, and the severity of symptoms.

If a therapist often works with special populations, or in specific environments, he or she might develop particular forms for each unique situation. A form for pregnant women would ask different questions than a form for athletes, or a form for elderly clients. A form for use in a spa will ask different questions than a form designed for on-site seated massage. The questions are formulated to highlight possible contraindications that might arise for a group or in relationship to specific techniques.  For example, a health intake for a spa environment will want to ask about allergies to shellfish or iodine if the spa uses seaweed-based products or offers seaweed treatments. Anyone allergic to shellfish or iodine is very likely to be allergic to seaweed, and even small amounts of it in lotions or skin care products can cause serious reactions.

You will want to customize your form with your logo, name, address, and phone number. These contact details should occur on every page of every document. This ensures that other relevant people can contact you easily for additional information in the event a client’s health records are subpoenaed for legal reasons or shared with another health professional.

Overview of a Health Intake Form for Wellness Massage

Let’s review the sample wellness health intake form shown in Figure 12-1. It is two pages long and will take clients approximately ten minutes to complete. It should be pointed out that the structure of the form, and the questions that are asked are up to the individual therapist. This is just one example of many designs, and you’re encouraged to look at a variety of health intake forms and then design your own forms to fit your particular needs. The school where you train is likely to have a form that is used in classes and in student clinic. The health intake form for a health care massage is shown and discussed in Chapter 19.

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The first section of the sample Wellness Health Intake form gathers general contact information from the client. It is helpful to know a client’s occupation because it often provides clues to a client’s muscular tension and postural habits. The second area of the form asks for the client’s primary health care provider. This information would be used in the event you needed a physician’s release to provide massage, or if the client had an adverse reaction to massage that was not so serious as to warrant a call to emergency services. Sometimes clients don’t have primary health care providers and wish to leave this section blank. It is okay if the client leaves this section blank, so long as an emergency contact has been listed.

In the third section the client outlines her goals for the session. This information provides a starting point for planning the session with the client. From Chapter 5 (Massage Cautions and Contraindications), Topic 5-2 you already understand how to use information on medications to adapt the massage to ensure client safety. The questions about pain, tenderness, stiffness, fever, inflammation, and fatigue alerts you that the client’s symptoms need further investigation before he or she can receive massage as discussed in Chapter 5, Topic 5-3 The final section (Current and Previous Conditions) allows the client to quickly provide an overview of his or her medical history. If the client checks that a condition occurred in the past it is less worrisome than a condition that is current. Still, past conditions often signal that greater caution is required. For example, if the client states that he or she had hypertension (high blood pressure) in the past, you might want to check the client’s blood pressure (Technique 5) before the massage to ensure that it is within normal parameters. Look up all unfamiliar medications and conditions to rule out contraindication before starting the massage.

Both the client and the therapist sign and date the form. This demonstrates that the intake process actually took place and that both have reviewed and agreed that the information on the form is up to date and complete. If a different therapist works with the client at a later date, he or she knows when the original health information was gathered and which therapist to contact in the event that more information about the client’s previous sessions is needed. The health intake form is kept in the client’s file and reviewed before every session. If a significant change in the client’s health occurs, (i.e., if the client is in an accident, sustains an injury, develops a medically diagnosed condition, is prescribed new medications, has surgery, etc.) the client is asked to update the form otherwise it is updated annually. The therapist or client can make simple amendments to the form if minor changes in the client’s health condition occur (i.e., the client stops smoking or a medication is switched by a physician, etc.). The new entry is dated and the initials of the therapist or client are placed beside the date.

Today’s Session Form

The form shown in Figure 12-2 is useful in a wellness massage process. The form is given to the client along with the health intake form. The human figures allow the client to quickly identify areas of pain and particular muscle tension. It also allows the client to mark the regions where she would like to receive massage and the areas she would prefer not to receive massage. A Today’s Session form might be used before every massage session to help the therapist quickly agree a plan for the massage with the client.

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