Massage Therapy

Swedish • Shiatsu/Acupressure • Thai

Relaxing massage that relieves stress & tension so you can live comfortably in your body.

• Single $85 • Series of Five $450 - good 3 months

• Series of Ten $800 - good 11 months

Aromatic Massage • Pre/Post Natal

Therapeutic and relaxing massage with the highest quality essential oils from plants, trees and flowers that replenish you and your body with abundant & positive energy.

• Single $95 • Ten $900 - good 12 months

Custom blends available for purchase.

Deep Tissue •Sports •Medical •Myofascial

Massage solutions that relieve pain, restore function & increase physical performance.

• Single $95 • 30 minutes twice/week for 3 weeks $275

• Evaluation plus Medical Massage $125 - 1.5hrs (required for new patients.)

Table Stretch

Relax and be stretched, aligned and decompressed. Relieve tight muscles & stiff joints so you can feel more spring in your step & enjoy greater freedom during movement.
• 25 minutes $45

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Personal Training Intake Forms (2)
To save you time, please fill these necessary forms out. Print them out, fill them out and bring them to your first appointment.

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE FORM 1

Name_______________________________________________________ Date______________________

The questions on this page are intended for your safety. Please check off yes answers:

1. Has your doctor ever said you have heart trouble or any cardiovascular problems? ______
2. Do you frequently suffer from tightness or pain in your chest or down your arm? ______
3. Have you ever suffered from a heart attack? ______
4. Do you ever experience an irregular or racing heart during exercise or at rest? ______
5. Do you often feel faint or have spells of severe dizziness? ______
6. Has a doctor ever said that your blood pressure is too high? ______
7. Do you often have difficulty breathing? ______
8. Are you pregnant? ______
9. Are you over age 65 and not accustomed to vigorous exercise? ______
10. Are you diabetic? ______
11. Is there a good physical reason, not mentioned here, for which you should not ______
follow a program of physical activity, even if you wanted to?

If you answered YES to any one or more questions, you MUST consult with a physician and provide written approval to Touch Fitness before you begin your exercise program.

Signature____________________________________________________Date______________________

Emergency Contact:

Name______________________________________________________Relationship________________

Phone: Home________________ Cell____________________ Work________________
Email________________

Address_______________________________________________________________________________

City_______________________________________ State_________________ Zip code_____________________

5) Brian, I want to add a button on every intake form page that says:
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EXERCISE HISTORY (Form 2)

Name__________________________________________________________________ Date____________________________________________

Address_________________________________________________________________ Email___________________________________________

Phone: Home______________________________________Work__________________________________Cell_____________________________

Referred by:_______________________________________Relationship____________________________Date of Birth______________________

What are your fitness/health goals?__________________________________________________________________________________________

How can Touch Fitness best help you to achieve your current goals?________________________________________________________________

Have you ever had a trainer before?__________If yes, what did you like/dislike about working with a trainer?______________________________

________________________________________________________________________________________________________________________

Are you exercising currently? Yes___________ No__________
If yes, number of days/week and minutes/day you currently participate in: Please circle activities that interest you now.:

Strength Training:______________________________________ Walking Jogging Running Swimming Pilates

Aerobic/Cardiovascular:_________________________________ Cycling Dancing Aerobics Spinning Step Class

Flexibility:____________________________________________ Strength Training In-line Skating (Rollerblading)

Alignment: ___________________________________________ Speed Skating Racquet Sports Yoga Climbing

Stress Reduction/Massage Therapy:_______________________ Skiing Snowboarding Cross Country Skiing

Recreational Activities:_________________________________ Stretching Other________________________.

Please rate your activity level from 1 to 3 (3 is most active) for each age range through your present age:

15-20yrs______ 21-30yrs______ 31-40yrs______ 41-50yrs______ 51-60______ 61-70______

Do you monitor your heart rate when you exercise? Yes__________ No_________

What is your ideal body weight?_________________What is your current weight?___________________How tall are you?___________________
Have you tried any diets? If yes, please list: _____________________________________________________________________________________
Have you been diagnosed with an eating disorder? If yes, please list: ____________________ Depression?_________________________________
If yes, are you currently being treated?________________________________________________________________________________________
Are you currently seeing a nutritionist? Yes__________ No_________
What vitamins, supplements and/or medications you are taking?__________________________________________________________________

Do you have problems sticking to an exercise program? If yes, please explain.________________________________________________________

________________________________________________________________________________________________________________________

How can Touch Fitness help you stick to an exercise program?_____________________________________________________________________

________________________________________________________________________________________________________________________
Do you have a partner, friend or spouse you can ask to workout with you on an ongoing basis? If yes, who?_______________________________

How physically fit do you feel right now? Check one: Great______ Moderate______ Poor______
Do you have any pain or discomfort right now?_________________________________________________________________________________
Have you had any surgeries, injuries or accidents?______________________________________________________________________________
Are you pregnant? Yes_______No______ If yes, number of months?______ __________________Other children?___________________________
Have you been working out prior to being pregnant? Yes_______No______ If yes, number of months? ___________________________________Do you have permission from your OB/Gyn to exercise while pregnant? Yes_______ No______ Permission to call? Yes_______ No_____
Name of physician, OB/Gyn...____________________________________________Phone Number_______________________________________

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Massage Therapy
• Medical Massage/Deep Tissue
• Maternity & Post-Natal Massage
• Essential Oil Delicious Massage
• Swedish/Relaxation Massage
• Sports/Event Massage
• Table Stretch
• Shiatsu/Acupressure
• Chair Massage

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Massage Therapy Intake Forms (1)
To save you time, please fill this necessary form out and click on the submit button.

Massage Intake Form

Name:_____________________________________________________ Date:__________________________
Address:______________________ Apt.:_________ City:_________ State:_________ Zip: ______________
Home Phone: ______________________ Work: _____________________________ Cell: ________________
Fax:_____________________
Email :______________________
Url:__________________________________
I prefer to have appointments confirmed at: _____ Home_____ Work_____Cell_____Email
Date of Birth: ______________________ Age: ____________
Children: yes____no_____ Names & Ages___________________________ (Optional)
Emergency Contact:______________________________ Relation:_______________Phone: ______________
Physician’s Name:________________________________ Phone:________________ Permission to call?_____
How did you hear about Touch Fitness?______________________
I prefer: _______Light _______Med. _______Deep _______Mixed Pressure
I prefer: ______Cold ______Heat
I prefer: __________Music
I prefer: _____Oil _____Cream _____Scented _____Unscented
What kinds of massage have you had?_______________________
Comments/Likes/Dislikes?__________________________________________________ ________________________________________________________________________Do you have any sensitivities or allergies to massage oils or creams? yes___ no ____
What is the primary reason for your visit?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ ________________________________________________________________________
Please list any injuries, accidents, surgeries, or fractures. (Include dates and treatments.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any past injuries, accidents, surgeries, or fractures. (Include dates and treatments.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________
What is your occupation? ___________________________________________ ________________________________________________________________________
Please list the Physical activities associated with occupation: _____________________________________________________________________________________________________________________________________________
List any discomforts you may feel from your occupation.
______________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list activity and frequency of exercise or athletic involvement.
________________________________________________________________________________________________________________________________________________
List any discomforts or injuries you are experiencing from exercise or athletics.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
Number per day of: cigarettes:______cups of coffee:______glasses of alcohol: ________other:_____________
Are you pregnant?___________ Number of months:________ Is this your first pregnancy?_________________
Do you have any metal rods, pins, plates, pacemaker surgically implanted in your body?_____________________________If so, where?_______________________
Please check off any current conditions and any previous conditions:
_____ Asthma _____ Herpes _____ Rheumatoid Arthritis
_____ Cancer _____ Hypertension _____ Scoliosis
_____ Colitis _____ Lipomas _____ Shingles (H. Zoster)
_____ Diabetes _____ Lyme Disease _____ Swelling in Joints
_____ Dizziness _____ Multiple Sclerosis _____ Tuberculosis
_____ Epilepsy _____ Osteoporosis/arthritis _____ Ulcers
_____ Heart Disease _____ Psoriasis/Excema _____ VaricoseVeins

Please list any medications, supplements, vitamins, or herbs you are currently using.
________________________________________________________________________

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Waiver
All clients must fill this out.
In order to ensure your safety and the high quality of service we provide, please take a few minutes to fill out these forms and send them back to us.
Thank you.

Agreement and Release of Liability

I, ________________________________, residing at ___________________________________________, do hereby waive, release, and forever discharge Touch Fitness and its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability from injuries or damages resulting from my participation in any programs of exercise and/or massage therapy. Program and/or session(s) may consist of Exercise, Evaluation, Massage Therapy and/or other related exercises and techniques. (Please initial______)

I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of Touch Fitness or the use of any equipment at 140 East 46th Street, Suite 6B, New York, NY 10017. (Please initial______)

Every effort will be made to minimize any discomfort and prevent injury by preliminary examination and by observations during situations which may arise. To my knowledge, I do not have any limiting physical condition or disability which would preclude a program of exercise and/or massage therapy. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation or use of equipment or machinery except as hereinafter stated. (Please initial______)

All participants prior to involvement in a fitness and/or massage program should obtain a physician’s examination. If a participant chooses not to obtain a physician’s permission, he/she must sign the following statement:

I do hereby acknowledge that I have been informed of the need for a physician’s approval for participation in a program of exercise and/or massage therapy. I accept complete responsibility for my health and well-being in the voluntary exercise and/or massage therapy, and related testing and understand that no responsibility is assumed by Sherrin Bernstein, Touch Fitness or any affiliated health facilities used during the program of exercise and/or massage therapy. (Please initial______)

I understand and am aware that strength, flexibility, and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death, and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death. (Please initial______)

I have read and agree to all the policies of Touch Fitness as well as the terms of this instrument and understand that I am signing a complete release and bar to any claim resulting from the programs, therapy and/or treatment herein described. In witness whereof, I, the undersigned, execute this release on the date set below.

Signature______________________________________________Date_____________

Witness_______________________________________________Date_____________

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