Intake Form - Client Information

Nombre        Male Female     Age:       

 

Date of Birthday       Marital Status Single Married          Weight    Height

 

  Address 

         City  State Zip

Telephone Cellphone

 

E-mail :

How did you find out about our services?

Referred by   Website    Yellow Pages   Sign   Ad  Other

 

Referred by Telephone

In Case of Emergency noticy

 

General & Medical Information

Occupation  Employer

Physician     Other Activities

Health Insurance Carrier

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral form your primary care provider may be required prior to services being provided.

 

YesNo Have you ever experienced a professional massage or bodywork session? How Recently?

 

If you answer "YES" to any of the following questions, please explain as clearly as possible.

 

YesNo    Do you frequently suffer from stress?

YesNo    Do you have diabetes?

YesNo    Do you experience frequent

                         headaches?

YesNo    Are you pregnant?

YesNo    Do you suffer from arthritis?

YesNo    Are you wearing contact lenses?

YesNo    Are you wearing dentures?

YesNo    Do you have high blood pressure?

YesNo    Do you suffer from epilepsy/seizures?

YesNo    Do you suffer from joint swelling?

YesNo    Do you have varicose veins?

YesNo    Do you have any contagious disease?

YesNo    Do you have osteoporosis?

YesNo    Do you have any allergies?

YesNo   Are you under a doctor, chiropractor

                       or other health care?

 

 

 

YesNo    Do your bruise easily?

YesNo    Have you had any broken bones in the past

                         two years?

YesNo    Have you been in an accident or suffered

                         any injuries in the past two years?

YesNo    Do you have tension or soreness in a specific

                        area? specifiy :                                         

YesNo    Do you have cardiac / circulatory problems?

YesNo    Do you suffer from back pain?

YesNo    Do you have numbness or stabbing pains

                         anywhere?

YesNo    Are you very sensitive to touch or pressure

                          in any area?, specify

YesNo    Have you ever had surgery? specify

YesNo   Do you have any other medical condition or are you taking any medications I should know about?

Why did you come for our Services?

 Relaxation  Pain  Therapy

What is your major complaint/Pain?

Head   Neck   Shoulder    Back   Arms   Legs

 

What activities or products have you used to address this conditions :

What activities aggravate this condition?

What activities improve this condition?

 

Please list any additional comments regarding your general well being, and past injuries, operations...

 

Date :