Spa Itinerary by qmc73115

VIEWS: 129 PAGES: 22

									Spa Itinerary
This is an example of an intake form used at a local spa.

Welcome to The Spa. For the comfort of our guests and to preserve our spa environment, cell
phones, pagers and beepers are not allowed in the Spa proper and locker rooms.

Though we make every effort to honor your preference for male or female therapists, we
cannot guarantee it.


 Date                  Start             Service               Price          Price w/ Gratuity
                       8:00A             Spa Admission
                       8:30A             European Facial
                       12:00P
                       2:30P             Swedish Massage


$18 DAILY SPA ADMISSION is charged to Day Guests in addition to Fitness Classes,
Treatments and Services.

7% ADDITIONAL GRATUITY & SERVICE CHARGE will be added to the printed price of each
Treatment, Service and Fitness Class.

JEWELRY: The Spa is not responsible for loss of personal items and valuables.We STRONGLY
urge you not to wear your jewelry in the Spa. Safety deposit boxes are available at the Inn
Front Desk.

CANCELLATION: 24-hours advance notice of cancellation is required to avoid 100% of the
reserved charge.

ALLERGIES AND HEALTH CONCERNS: Please let us know of any health concerns you may
have today - such as:
  ANY allergies to foods, products, substances or fragrances
  Are PREGNANT or suspect you may be PREGNANT
  Have High or Low Blood Pressure or Diabetes
  Are taking medication, have a rash, infection or nail fungus




   I HAVE READ AND UNDERSTAND THESE REQUESTS:

   ________________________________




Connecticut Center for Massage Therapy                     1                 Spa Massage 2
Connecticut Center for Massage Therapy   2   Spa Massage 2
Sample Treatment Menu

Name_____________________________________________

Address__________________________________________________________________

Phone numbers: Home ________________ Work ___________________

The spa is not responsible for jewelry or other personal items. We strongly suggest you do
not wear jewelry. A strong box is available for your use at the front desk.
½ hour treatments: $50.00 1 hour treatments: $85.00 1½ hour treatments: $120.00
5% ADDITIONAL GRATUITY & SERVICE CHARGE will be added to the price of each treatment.
24-hours advance notice of cancellation is required to avoid 100% of the reserved charge.
Treatments:
Massage Treatments                          Body Treatments
   ___Swedish massage                          ___Body Scrubs
   ___Athletic massage                         ___Body Mask
   ___Reiki                                    ___Collagen Paraffin
   ___Hydrotherapy                             ___Raindrop
   ___Lymphatic Drainage                       ___Rose Glow
   ___Thai Massage                             ___ Back ‘Facial’
   ___Hot Stone Massage                        ___Frankincense Treatment
   ___Lomi Lomi                                ___Tansy Poultice
                                               ___Mud Bath
Facials                                        ___Warm Water Jacuzzi
   ___Facial Rejuvenation                      ___Honey and Nutmeg Scrub
   ___Champagne Facial                         ___Salt Glows
   ___Vitamin Application                      ___Caster Oil Pack
   ___Hot Oil Hair Treatment                   ___Ginger Poultice
   ___Paraffin Facials                         ___Mustard Poultice

Foot Treatments
   ___Peppermint Foot Soak
   ___Paraffin Foot Soak
   ___Ginger Foot Soak

Codes:




Please complete the back of this form.




Connecticut Center for Massage Therapy             3                          Spa Massage 2
Occupation & Posture assumed most during day _________________________________________

________________________________________________________________________________
Areas of Tension (check all that apply):
        __   Head/Face                    __   Upper Back                  __   Hips
        __   Neck                         __   Mid Back                    __   Buttocks
        __   Shoulders                    __   Low Back                    __   Legs
        __   Chest                        __   Abdomen                     __   Feet
        __   Arms/Hands

Medical History - Please indicate below any significant medical conditions:

__ Skin condition (e.g. rash, dermatitis, eczema)

__ Circulatory condition (e.g. heart disease, varicose veins, arteriosclerosis, high/low blood pressure)

__ Lymphatic condition (e.g. swollen glands, lymphedema)

__ Neurological condition (e.g. sciatica, numbness/tingling in any area of body, stroke, epilepsy)

__ Endocrine system (e.g. hormone imbalances, diabetes)

__ Joint problems (e.g. hypermobility, arthritis, sacroiliac problems)

__ Bone conditions (e.g. osteoporosis, cancer)

__ Headaches (e.g. migraines, tension, PMS)

__ Emotional difficulties (e.g. depression, anxiety, mood swings)

__ Accidents (please describe):



__ Injuries (please describe):



__ Surgeries (please describe):



Medications - Please list any currently being taken:



Exercise Level (please describe type & frequency):




Client Signature: __________________________________ Date: _____________________




Connecticut Center for Massage Therapy                          4                                 Spa Massage 2
Client Questionnaire
In order to maximize the effectiveness and safety of our sessions together, we ask that you take the
time to fill out this confidential questionnaire carefully.

Client Initials: ________        Client Number: _________           Date: __________ Referred by: ___________
Address: ____________________________________________________________________________
Phone (day): ______________________ (eve): _____________________ Date of Birth: ___________
Occupation(s): _______________________________________________________________________
Age: __________               Height: __________             Weight: __________          Build: _______________

What brings you here today?


Is there any area where you would like extra time spent? Is there any area where you have muscle
pain/stiffness/tension (neck, low back, shoulder, other)?


What is your previous experience with professional massage?


Daily activities / sports / hobbies: ________________________________________________________

Habits:      Exercise (types and frequency) ______________________________________ Sleep ______________
             Tobacco ___________ Alcohol _________ Drugs (non-med.) ___________ Caffeine ______________
             Posture assumed most of day ____________________________________ Bowels ________________

Medical History - Please indicate below any significant medical problems, as such conditions can
influence the type and/or depth of work done in any given area. Thank you.
______    Allergies
_____     Skin condition (acne, rash, allergies, skin cancer, other):
_____     Lymphatic condition (swollen glands, lymphoma, lymphedema, other):
_____     Recent injury or accident (whiplash, sprain, deep bruise, other):
_____     Circulatory condition (heart disease, varicose veins, phlebitis, arrhythmia, arteriosclerosis, other):
_____     Neurological condition (sciatica, numbness/tingling of any area of skin, stroke, epilepsy, other):
_____     Joint problems, pain, or stiffness (osteoarthritis, rheumatoid arthritis, gout, hypermobile joints, sacroiliac
          problems, other):

_____     Can you lie comfortably on your stomach?_______ Can you lie comfortably on your back?_______
_____     Bone conditions (osteoporosis, previous fracture, cancer, other):
_____     Headaches (migraines, PMS, tension, cluster, other):
_____     Emotional difficulties (depression, anxiety, psychotic episodes, other):
_____     Stress
_____     Previous surgery, please state type and date:
_____     Other medical considerations:
_____     List any medications you are currently taking:

_____ Are you pregnant?
______ Do you have any body piercings that would be effected by heat (such as belly piercings?
Name of Health Care provider (not Insurance Co.):___________________________________

Phone:_____________________

Do we have permission to contact him/her should the need arise?                  Yes_____ No ______

Connecticut Center for Massage Therapy                             5                                 Spa Massage 2
Client understands that the massage will be administered by a student enrolled in a massage program at the Connecticut
Center for Massage Therapy. The student practitioner is not a licensed massage therapist.
The student practitioner is neither trained nor licensed to provide medical treatment to diagnose, prescribe drugs or
medicines, perform spinal or other joint manipulations, nor any other service which a license to practice medicine,
chiropractic, naturopathy, physical therapy, or podiatry is required by law.
Student practitioner, faculty, and school make no claims, representations, or guarantees about specific results. The goal of
this session is primarily for the practice time of the student. If there are specific therapeutic needs perhaps a licensed
therapist should be consulted.
Client has been provided with descriptions of the service and anticipated benefits. Client understands and agrees to the
purpose, nature, and duration of the proposed service, and consents to receive this service.
Client understands that there can be remote risks associated with this work. Client acknowledges that the student practitioner,
faculty, staff, and school will not be responsible for any injury arising because of some unreported condition and/or concern.
Client acknowledges being given the opportunity to ask questions before receiving any work, and to question or interrupt the
work at any point after session begins.
Client acknowledges having read and understood this document.

                  ___________________                _________________________________________
                         Date                                        Client Initials only


Notes For Discussion of Questionnaire:
Notes on goals/concerns of client...experience with massage:

Highlight any major concerns from medical history.                   Gather information indicated below on EACH
concern you feel the need to research further.
      Is there a "diagnosis" that you can research, or has the client described a symptom? What is the
      diagnosis?



      Who diagnosed it? (especially important, find out the type of health care provider, i.e. M.D.,
      chiropractor, naturopath, physical therapist, etc.)

      When did the condition begin?                    When was it first diagnosed?



      How does it affect you now? (What are the symptoms?)



      What seems to help it the most? (Especially ask for any information on positioning, exercise,
      hydrotherapy, rest, in addition to what the client offers spontaneously)




      What seems to make it worse? (Include same type of information as above)



      Are you taking any medications for it at the present time?

      Are you currently under the care of a physician for this condition?



Connecticut Center for Massage Therapy                                6                                   Spa Massage 2
                           Sample Chair Massage Intake Form

What is on-site massage?                    The acupressure massage you are about to
                                            receive is not appropriate for everyone. Please
On-site (OSM) massage is the most           read the following information carefully and
versatile style of bodywork being offered   answer the questions before your on-site
in the world today. Because it is done      massage. Your practitioner will discuss this
on seated clients, OSM can be offered       information with you.
almost anywhere to anybody.
                                            Have you had a massage before?
This particular on-site massage is based    Yes         No
on a traditional acupressure sequence
which, in 15 minutes, includes the neck,    If so, have you had an acupressure massage?
shoulders, back, arms hands, and scalp.     Yes           No
OSM is designed to enhance circulation
making you feel vibrant and refreshed.      Have you eaten within the last 7 hours?
                                            Yes         No
Now you can enjoy the tremendous
stress-reduction benefits of massage in     Do you have any chronic pain, medical
the convenience of your office and at a     conditions, or recent injuries or illnesses?
price that you’ll feel even better about.   Yes           No
Give yourself the treatment you deserve
and your body the relief it demands.        Are you under a doctor's care or taking any
                                            medication?
This massage should feel comfortable.       Yes         No
During the massage your practitioner
will ask you if the pressure being          Have you had any recent falls, surgeries,
applied is appropriate. The "OK" sign       accidents, or traumas?
means that the pressure is perfect for      Yes           No
you. “Thumbs up" means that you
would like more pressure. "Thumbs           Do you participate in regular exercise?
down" means that you would like less        Yes          No
pressure.

_______________________________             A special note: Some of the acupressure points
For further information about our           in this massage are not appropriate for
services:                                   pregnant women. Please tell your practitioner if
                                            you are pregnant or are trying to get pregnant.
Name_____________________________

Address___________________________

City/State/Zip________________________




Connecticut Center for Massage Therapy          7                            Spa Massage 2
Connecticut Center for Massage Therapy   8   Spa Massage 2
                                  Spa Massage Log Summary Page

NAME:_____________________________________________ TERM:________

SECTION:__________                 MAILBOX:____________
Please update this page as a cover sheet each week; keep the cover sheet in front of your loose-leaf notebook.
Please include all your work done to date.

The Spa Massage requirement is to document 12 hours of log time divided as follows:
      Giving                                               Receiving
      1 hour seated (4-15 minute sessions)                 ½ hour seated (2-15 minute sessions)
      2 hour side-lying                                    1 hour Side-lying
      9 hours integrated techniques with                   2 ½ hours integrated techniques with
               Classic Western massage                                  Classic Western massage
      12 hours total giving                                4 hours total receiving

As part of 2 logs, include 3-session client plan
As part of 3 logs, include body maps

              Logs have to be given on a minimum of 6 different people out of class time.

           Massage     Massage       Seated     Seated          Side      Side      Body    Client Plans   Complementary
 Week
            Giving     Receiving     Giving    Receiving       Giving   Receiving   Maps   (check if you    techniques or
                                                                                                use)          modalities
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 Total

TOTAL Giving and Receiving Required:

          (12 hrs.)    (4 hrs.)

Connecticut Center for Massage Therapy                     9                                           Spa Massage 2
Connecticut Center for Massage Therapy   10   Spa Massage 2
                                   Spa Massage Giving Log

Date: ____________                       Receiver’s initials: _________   Client Number ________
Total Hands-on Time ____________               Classic Western Time __________
Technique used________________________________ Time__________

S: SUBJECTIVE The information your client tells you prior to the massage session.

   What does the Client Questionnaire tell you about this client?




   What areas of tension and/or existing symptoms/conditions are identified by the client?




   What aggravated; what relieves these identified symptoms/conditions?




   What are the client’s goals for this session?




O: OBJECTIVE Your visual and palpatory observations regarding this client before and
             during the session, procedures/techniques used, and session goals.

   What are your practice objectives for this session?




   What procedures were followed toward the identified, therapeutic goal?




   What were the palpation findings?




Connecticut Center for Massage Therapy               11                                    Spa Massage 2
A: ASSESSMENT: The changes that you observe in your client’s body during and after the
               session.

   What were the observed results and changes?




  What was the response of the receiver?




P: PLAN: Your review of effectiveness of this session and your recommendations for
         future sessions.

   What are the plans/objectives/ intentions for future session?




   What are the client homework recommendations?




ADDITIONAL COMMENTS:

   What did you learn from this session?




Connecticut Center for Massage Therapy            12                        Spa Massage 2
                                Spa Massage Receiving Log

Date: __________ Total Hands-on time_____ Giver’s initials: _______ Licensed MsT___ or Student___
Classic Western ________        Technique used _______________________________ Time_______

SUBJECTIVE The information you as a client tell the therapist about health history, current
   needs and reason(s) for coming to the massage session.
Problems/concerns communicated to the therapist (health history, tightness, pain, TPs, restricted ROM,
   mind/body issues)




What makes the concern better or worse? (position, activity, therapies)




What is/are your goal(s) for the session? (areas of focus, decrease of pain, relaxation, practice strokes,
learn from therapist’s experience)




O: OBJECTIVE Your palpatory observations and the procedures/ techniques used during
             the session.
   Techniques used (strokes, stretching, specific areas of concentration or full body)




  Palpation findings (areas of focus, muscles involved, textures of tissues as you perceive them, levels
  of hyper- or hypo-sensitivity)




A: ASSESSMENT: The results of the session.

   The effects of the strokes on your body in the areas of concern and the over-all effect of the work.




Connecticut Center for Massage Therapy             13                                       Spa Massage 2
P: PLAN: Future plans, homework suggested, learning(s) from the session.

   Observations about the therapist (sensitivity and effectiveness in application of pressure,
   professionalism, quality of strokes, communication/rapport, sense of connectedness, flow,
   environment)




   Did the therapist address your needs? Please explain how or how not. Did you
   communicate your needs during the session?




   What suggestions or homework did the therapist offer?




   What was and wasn’t effective for you? (like/dislike) What would you do again? What
   would you do differently? (goals, strokes, focus)




ADDITIONAL COMMENTS:


   What did you learn about your own self care?




   What did you learn from the session about massage in general or your own mind/body?




Connecticut Center for Massage Therapy        14                                   Spa Massage 2
                                        Spa Massage
                                   THREE SESSION PLAN A
                                       Hypothetical
Therapist: _________________________         Date: ____________________

Receiver: __________________________

Concern/ Condition of the client: ________________________________________

Session 1: Plan of Action




Session 2: Plan of Action




Session 3: Plan of Action




Connecticut Center for Massage Therapy      15                            Spa Massage 2
Connecticut Center for Massage Therapy   16   Spa Massage 2
                                        Spa Massage
                                   THREE SESSION PLAN B
                              Client that you have worked on once

Therapist: _________________________           Date: ____________________

Receiver: __________________________

Concern/ Condition of the client: ________________________________________

Session 1 - Plan of Action:




Actual Session Date: _______________
Description of the session:




Session 2 - Plan of Action:




Connecticut Center for Massage Therapy        17                            Spa Massage 2
Session 3 - Plan of Action:




Connecticut Center for Massage Therapy   18   Spa Massage 2
                                        Spa Massage
                                   THREE SESSION PLAN C
                                          Actual
Therapist: _________________________          Date: ____________________

Receiver: __________________________

Concern/ Condition of the client: ________________________________________

Session 1: Plan of Action




Actual Session Date: _______________
Description of the session:




Session 2: Plan of Action




Actual Session Date: _______________
Description of the session (include new treatments and modalities you used):




Connecticut Center for Massage Therapy       19                                Spa Massage 2
Session 3: Plan of Action




Actual Session Date: _______________
Description of the session (include new treatments and modalities you used):




Connecticut Center for Massage Therapy       20                                Spa Massage 2
Connecticut Center for Massage Therapy   21   Spa Massage 2
Connecticut Center for Massage Therapy   22   Spa Massage 2

								
To top