Intake Form
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Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
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Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
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Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
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Bosnia And Herzegovina
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Bouvet Island
Brazil
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Brunei Darussalam
Bulgaria
Burkina Faso
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C?te D'Ivoire
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Chad
Chile
China
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Congo, The Democratic Republic Of The
Cook Islands
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Cuba
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Gabon
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Guinea
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Heard Island And Mcdonald Islands
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Honduras
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Hungary
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Iraq
Isle Of Man
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Korea, Republic Of
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Panama
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Romania
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Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
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Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Conditions
Treatment Goals
Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Other
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Massage Goals
Address Health Issues
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Strength Training
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Alternative Therapy
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Stress Relief
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Balance
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Flexibility
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Improve Fitness
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Increase Well-Being
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Injury Rehabilitation
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Positive Reinforcement
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Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Medium Pressure Preferred
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Other
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Deep Pressure Preferred
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Allergy
Latex
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Medical
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Miscellaneous
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Environmental
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Food
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you been tested for COVID?
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Fever Over 100.4 degrees
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New Onset of Cough
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Sore Throat
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Shortness of Breath
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Difficulty Breathing
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Fatigue
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Chills
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Pink eye (conjunctivitis)
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Nasal or sinus congestion
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Runny nose/nasal congestion without other known cause
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Sudden onset body aches
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New rash or other skin changes
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Regular cardio exercise
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Contact with someone with COVID
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Contact with someone who was in contact with COVID
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Contact with anyone with acute respiratory Illness
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Recent travel to area with high infection rates
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Been in group where social distancing not observed
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Are you considered high risk?
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Spend time around anyone that is high risk
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Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
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