Rooted Integrative Wellness Intake

*FILLING OUT THIS FORM DOES NOT MEAN THAT YOU HAVE REQUESTED AN APPOINTMENT. PLEASE CALL (520) 326-8300 TO SCHEDULE*

First Name

Last Name

Pronouns

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Mobile Phone

Home Phone

Work Phone

Source of Referral

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor's Name

Doctor's Phone

Doctor's Address

Have you been in a Motor Vehicle Accident?

If yes, do you plan to bill your massage treatment to your car insurance?

Please provide details including dates, treatment, and a brief description of the accident.

PLEASE NOTE: The following list of conditions isn't exhaustive. Please use the "Other" fields at the bottom to provide any missing conditions or details.

Neck

Upper Back

Mid Back

Low Back

Chest

Abdomen

Arm(s)

Shoulder(s)

Elbow(s)

Wrist(s)

Hand(s)

Leg(s)

Hip(s)

Knee(s)

Ankle(s)

Feet

Tension

Sinus

Migraines

Cluster

Rebound

Chronic Daily Headache

Tingling or Numbness

Sciatic Pain

Herniated Disc

Vertebral or Spinal Cord Injury

Brain Injury

Multiple Sclerosis

Transient Ischemic Attack (TIA) or Stroke

Epilepsy or other seizures

Other (please specify)

Blood Pressure (high or low; please specify)

Heart Attack

Cardiac Arrhythmia

Aneurysm

Blood Clots

Varicose Veins

Lymphedema

Pacemaker

Congestive Heart Failure

Myocardial infarction

Other (please specify)

Ovarian Cysts/Tumors

Pelvic Inflammatory Disease

Endometriosis

Other (please specify)

Allergies

Rheumatoid Arthritis

Anaphylaxis

Lupus

Fibromyalgia

Chronic Pain Disorder

HIV or AIDS

Cancer (please specify)

Other (please specify)

Strain/Sprain

Joint Injury

Tendonitis/Bursitis

Arthritis (osteo-)

Fracture

Dislocation

Surgical pins, plates, or other hardware

Artificial Joints / Special Equipment

Ankylosing Spondylitis

Scoliosis (genetic or functional)

Osteoporosis

Other (please specify)

Irritable Bowel Syndrome

Ulcerative Colitis

Diverticulitis

Crohn's Disease

Constipation

Diarrhea

Eating Disorder

Celiac Disease

Other (please specify)

High Cholesterol

Thrombosis/Embolism

Hepatitis

Hemophilia

Anemia

Other (please specify)

Rash

Psoriasis

Bruise Easily

Fungal conditions (e.g. athlete's foot)

Melanoma/Carcinoma

Infectious Skin Conditions

Other (please specify)

Asthma

Chronic Cough

Shortness of Breath

Bronchitis

COPD

Cystic Fibrosis

Other (please specify)

Tinnitus

Vertigo

Hearing Loss

Sinus problems

TMJ disorder/dysfunction, jaw pain

Vision problems

Vision loss

Other (please specify)

Kidney Stones

Urinary Incontinence

Kidney Disease (specify)

Diabetes

Hyperthyroidism

Hypothyroidism

Other Medical Conditions (specify)

Are you currently pregnant?

High risk pregnancy

Rooted Integrative Wellness Policies and Agreements (Review Required)

You need to review and accept this before submitting