Amazing Hands Client Intake v2.1
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Personal Info
First Name
Last Name
Pronouns
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
Identify as
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Occupation
Contact Info
Mobile Phone
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Source of Referral
Address
City
Country
Australia
Canada
Ireland
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Afghanistan
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Bolivia, Plurinational State Of
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Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
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C?te D'Ivoire
Cambodia
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Central African Republic
Chad
Chile
China
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Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
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Djibouti
Dominica
Dominican Republic
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Faroe Islands
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Greece
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Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
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Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
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Palestinian Territory, Occupied
Panama
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Pitcairn
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Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
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
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Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
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
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Visiting or traveling
Are you
A Local
Visiting
A Frequent Visitor
Alternate address (either where you're staying i.e. hotel, or permanent address if you listed a local address above)
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Massage History & Goals
Massage History
Have you had massages before?
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1
2
3
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5
6
7
8
9
10
This is my first massage
I've had a lot of massages
Describe your massages: Deep, Light, Sports, Chair, Etc.
How often do you get massages? (How many each year)
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1
2
3
4
5
6
7
8
9
10
Less than once a year.
Monthly or more
When was your last massage
When was your last massage
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1
2
3
4
5
6
Recently/This year
More than 5 years ago
What are your goals
Address Specific Health Issues
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General Wellbeing
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Sports Care
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Injury Rehabilitation
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Pain Relief
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Tension
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Improve Flexibility
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Stress Relief
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Headache
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Improve Sleep
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Relaxation
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Feather light / Swedish Only (ASK: We may recommend an hour maximum)
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Other
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Recent Injury: If focus of todays visit
Date Of Injury
Cause of Injury
Work
Play
Home
Auto Accident
Other
Have you talked to insurance yet?
Yes
Yes, I have approval for massage therapy
No, but I plan to
No, I do not plan to
Have You seen a doctor for these issues?
Yes
Yes, I have approval for massage therapy
No, but I plan to
No, I do not plan to
Name and Contact info for the Doctor
Todays Focus
Focus on
Avoid
I need a feather light touch
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I need more pressure
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I need less pressure
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Heat/Cold Therapies
I want heat therapy (Neck Roll)
I want heat therapy (Heating Pad)
I want cold therapy (Ice Pack)
I want cold therapy (Neck Roll)
Other
Heat/Cool Therapy Note
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I request essential oil therapy ($5): Typical oils on hand: Peppermint, Lavender, Eucalyptus, Woodsy (Blend), Refreshing (Blend)
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Exercise
What are your exercise routines and frequencies
Yoga
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Thai Chi
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HITT
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Weight Training
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Cardio (List Preferred Cardio)
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Sports (What Sports)
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Other
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Are you Training (goal/outcome/program/etc)
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Medical massage?
Professionals
Date of last Physical Therapy appointment for todays issues
Date of last chiropractic appointment (For any reason)
Chiropractor's name, or if your last visit was a long time ago note that
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Are you visiting for a medical massage?
Yes
No
I don't know
HSA/FSA/Insurance: Are you planning to
Self pay basic documentation
Self pay detailed documentation
Use an FSA/HSA card
Submit for FSA/HSA reimbursement
Self Submit to insurance
Having us submit to insurance (currently only pre-approved VA/community care)
We're you referred by a physician? (Name & number)
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Do you have a prescription/written referral (Add referral/approval number)
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Do you have diagnosis (include ICD codes if possible)
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Did they list stated goals
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A number of sessions
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An expiration date
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Injuries
Injury
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Medications
Medication
Add Another Medication
Medical Conditions
Accident
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Addiction
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Allergies/Sensitive to perfumes, lotions, or oils
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AIDS/HIV
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Arthritis
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Asthma
Autism
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Back/Neck Issues
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Balance issues
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Blood Clots or TIA
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Blood Pressure: High/Low/Controlled
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Broken Bones (Current or released in last 90 days, or historically significant)
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Bruise Easily
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Cancer
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Circulation Problems
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Concussion (Currently affected or under protocol within the last 6 month)
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Diabetes
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EDS
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Fainting
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Fibromyalgia
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G.I. Problems
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Headaches
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Heart Disease/CHF/Other Heart Issues
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Joint Issues (Stiffness, Swelling, Injury, Gout, Other)
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Hepatitis
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Lime disease
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Nerve: Numbness, Tingling, Neuropathy, Loss of sensation/feeling
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Mental / Emotional Distress / PTSD (Triggers in massage?)
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Mononucleosis
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MRSA (Current or Past)
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Osteoporosis
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Sciatic Pain
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Pregnant/Trying (Within the last 6 months)
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Restless Leg Syndrome
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Scoliosis
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Skin Sensitivity
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Sprains
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Seizures
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Spinal injuries
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Stroke
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Ticklish
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TMJ
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Tuberculosis
Varicose Veins
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Weak tissues or joints
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Whiplash
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Implants, body modifications, or surface accessories (including joint replacements, pacemakers, medication, sensors and jewelry) : Surgery list below
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Surgeries
Surgery
Add Another Surgery
Body Modifications
Surgries not listed above? Implants, BODY modifications, or SURFACE accessories; including joint replacements, pacemakers (Including Pain, Seizure, Mobility devices), MEDICATION (i.e. Norplant), SENSORS, and JEWLERY)
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Lifestyle information
Smoke (packs per week)
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Drink alcohol (drinks/week)
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Servings of caffeine/week (what forms)
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How many 8oz glasses of water do you drink per day
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Recreational Drugs
Never
Rarely (1-4/year)
Occasionally (~6-12/year I.e . monthly or multiple special events)
Frequently (once or twice a week)
Daily
:
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I would like help overcoming an addiction or reducing my frequency of drugs, alcohol, smoking, caffeine, sugar, etc
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Diet
Low fat
Low carb
Mediterranean
Vegetarian
Vegan
Special program
Other
No special diet
Explain:
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Insurance
I have insurance
Insurer
VA CCN Optum
Policy Name
Policy / Group / Plan #
Member ID / Certificate #
Policy Holder
I'm not the policy holder.
First Name
Last Name
Relationship To Patient
Child
Parent
Spouse
Common Law Spouse
Other
Date of Birth
Address
City
Prov / State
Postal / Zip Code
Phone Number
Related Details
Referring Provider
Prescriber
First Name
Last Name
Prior Authorization Number
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