Amazing Hands Client Intake v2.1c
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Personal Info
First Name
Last Name
Pronouns
Date of Birth
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1911
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1907
Gender
Male
Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
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
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
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
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
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
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
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
Sint Maarten
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
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
Work/Occupation/Hobby (Pick as many as apply)
I sit a lot
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I stand a lot
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I contort myself a lot (Squeeze under cars, into cabinants, under sinks, attics, on ladders, etc.)
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I drive a lot
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I walk a lot
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I do a lot of repetitive actions (what? i.e., Cashier, assembly line worker, picker, etc.)
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I do heavy labor (what? i.e. construction, warehouse, mechanic, etc.)
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I change positions a lot
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I have a high stress job
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I work in an extreme environment (vibration, hot, cold, etc)
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Challenging Schedule (Random, early morning, late nights, or split shifts)
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After work I head straight to the recliner (Couch potato or just worn out?)
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I sleep on the recliner or couch
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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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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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Less than once a year.
Monthly or more
When was your last massage
When was your last massage
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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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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
Work is Exercise
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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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Injuries
Injury
Add Another Injury
Recent Injury: If focus of today's 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
***You can add more information later***
We have a section specifically for medical massage information
Medications
Medication
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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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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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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)
Are you visiting for a medical massage?
Yes
No
I don't know
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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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
Full Time Student
Part Time Student
Handicapped Dependent
Date of Birth
Month
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2025
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2020
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2015
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1941
1940
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1911
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Address
City
Prov / State
Postal / Zip Code
Phone Number
Related Details
Referring Provider
Prescriber
First Name
Last Name
Prior Authorization Number
Quick Reminders & Policy List
I understand there are two locations, and I will verify the location when scheduling.
I understand the 48-hour cancellation policy; 72 Hours for any service valued at more than $150 or involving more than one therapist. There is a 15 minute grace period after booking
I understand that when canceling, I need to call or text 816-210-4077
I understand that when booking online, I need to notify the therapist of the booking by messaging or calling 816-210-4077
I understand that the published number is a land line that does not receive text messages. 816-210-4077 is our text/cancelation/appointment verification line.
Review & Agree
Intake Consent
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Payment and Cancelation Policy
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Privacy Policy
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