Elite Muscle Therapy - Client Clinical Information & Intake Form

Required Field

Personal Info

First Name

Last Name

Pronouns

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Contact Info

Mobile Phone

Home Phone

Work Phone

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor

Doctor's Name

Doctor's Phone

Doctor's Address

Other

We celebrate diversity and want to create an inclusive environment at the clinic - is there anything we can accommodate for you during your treatment?

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Have you received COVID-19 vaccination/s?

Yes - FIRST

Yes - BOTH plus booster/s

Health Information

Allergies and Immune Sytem

Current / Recent Infectious Conditions

Bloodborne Illness (including HIV / AIDS / Hepatitis - please specify)

Cough / Cold / Flu / Other Respiratory Illness in the past 2 weeks?

Measles / Mumps

Pneumonia / Chest Infection

Strep throat

Other Infectious Disease

Not applicable

General Health Questions

Blood / Vascular

Bleeding Disorder (please specify)

Blood Thinning Medication (please specify)

Haemophilia

Varicose Veins (please specify)

Other Blood Disorders

Not applicable

Medications (including supplements and self prescribed medications)

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Musculoskeletal

Neurological

Respiratory

Asthma

Chronic Obstructive Pulmonary Disease (COPD)

COVID or Long COVID

Emphysema

Infectious Respiratory Conditions (please specify)

Tuberculosis

Other Respiratory Condition

Not applicable

Skin

Area of Complaint

General Injury Related Questions

Previous injuries?

Treatment of previous injury?

Ongoing complications from any injury?

Pain medications or steroids (please specify)

What is the next competition / challenge / event / race?

Not applicable

Your Massage

How often do you usually receive massages?

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Where and when was your last massage? (please specify)

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Have you received Dry Needling previously?

Yes

Would you like Dry Needling to be incorporated into your treatment plan? We will address this during your consult.

Have you received Cupping previously?

Yes

Would you like Cupping to be incorporated into your treatment plan?

Light / Medium / Deep Pressure Preferred (please specify)

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OPTIONAL - What sort of music would you prefer to be playing during your massage?

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Additional information - is there anything else we should know about you or your condition/s?

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Thank you for taking the time to fill in your client intake form - this information helps us determine an appropriate treatment plan for you.

All of your details are private and secure, and will not be shared outside of our clinic without your consent.

If you have any questions, please text your therapist or ask during your consult.

- The Elite Muscle Therapy team