Massage Therapy – New Client Intake & Consent Form

Complete this section only if your massage therapy services have been referred or authorized through the Department of Veterans Affairs (VA).

Are you receiving massage therapy through a VA referral or authorization?

Yes

Not Sure

Do you have a VA referral or authorization number?

Yes

Not sure

Referring VA facility or provider (if known)

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Authorization dates (if known)

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Authorization dates (if known)

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Left Side of Neck

Right Side of Neck

Left Side of Upper Back

Right Side of Upper Back

Left Side of Mid Back

Right Side of Mid Back

Left Side of Low Back

Right Side of Low Back

Chest

Abdomen

Left Arm

Right Arm

Left Shoulder

Right Shoulder

Left Elbow

Right Elbow

Left Wrist

Right Wrist

Left Hand

Right Hand

Left Leg

Right Leg

Left Hip

Right Hip

Left Knee

Right Knee

Left Ankle

Right Ankle

Left Foot

Right Foot

Migraines

Headaches

Cluster

Rebound

Sinus

Chronic Daily Headache

Tension

Tingling

Multiple Sclerosis

Brain Injury

Stabbing

Cerebral-vascular Accident

Cerebral Vascular Accident (Stroke)

Sciatic Pain

Loss of Sensation

Seizure Disorder

Stroke

Transient Ischemic Attacks (TIA)

Vertebral and Spinal Cord Injury

Epilepsy

Shingles

Cerebral Palsy

Huntington Disease

Dizziness

Parkinsons

Brain Disorder

Numbness

Burning

Herniated Disc

Chronic Pain Disorder

Cardiovascular Conditions

Congenital Heart Defect

Varicose Veins

Heart Attack

Blood Pressure

Acute Coronary Syndrome

Coronary Artery Disease

Blood Clots

Phlebitis

Aneurysm

Hyperlipidemia

Lymphedema

Cardiovascular Accident

Angina

Pericarditis

Pacemaker

Atherosclerosis

Raynaud Disease

Cold Hands

Heart Disease

Cardiac Arrhythmia

Rheumatic Heart Disease

High Blood Pressure

Cold Feet

Chronic Ischemic Heart Disease

Valve Disorders

Low Blood Pressure

Chronic Venous Insufficiency

Myocardial infarction

Congestive Heart Failure

Menstrual Cycle Disorder

Ovarian Cysts/Tumors

Pelvic Inflammatory Disease

Premenstrual Syndrome

Pregnancy

Uterine Disorder

Gynaecological Conditions

Breast Disorder

Ectopic Pregnancy

Endometriosis

Menopause

Non-Hodgkin Lymphoma

Rheumatoid Arthritis

Anaphylaxis

Allergies

Lupus

Hodgkin Lymphoma

Infectious Mononucleosis

Cancer

Leukemia

Hereditary/Congenital Deformity

Strain/Sprain

Joint Injury

Amyotrophic Lateral Sclerosis (ALS)

Osgood-Schlatter Disease

Osteoporosis

Muscular Dystrophy

Osteoarthritis

Ankylosing Spondylitis

Gout

Osteomalacia

Myasthenia Gravis

Tendonitis/Bursitis

Bone Disease

Paget Disease

Sinus Problems

Compartment Syndrome

Psoriatic Arthritis

Artificial Joints / Special Equipment

Dislocation

Scleroderma

Fibromyalgia

Fracture

Arthritis

Jaw Pain (TMJD)

Scoliosis

Constipation

Digestive Conditions

Poor Appetite

Diarrhea

Stomach Disorder

Crohn's Disease

Diverticulitis

Ulcerative Colitis

Eating Disorder

Esophageal Disorder

Fecal Impaction

Intestinal Polyps

Celiac Disease

Irritable Bowel Syndrome

Hypercoagulability

Hepatitis

Polycythemia

Haemophilia

HIV

Thrombosis/Embolism

High Cholesterol

Anemia

Bleeding Disorder

HIV/AIDS

Acne

Athlete's Foot

Psoriasis

Allergic Dermatosis

Rash

Bruise Easily

Athletes Foot

Herpes

Hypersensitive Reaction

Rosacea

Chemical Burn

UV Burn

Hypersensitive Reactions

Melanoma

Melanoma/Carcinoma

Skin Conditions

Infectious Skin Conditions

Pigmentary Disorder

Skin Irritations

Plantar's Wart

Chronic Cough

Respiratory Conditions

Shortness of Breath

Asthma

Tuberculosis

Emphysema

Bronchitis

Respiratory Tract Infection

COPD

Cystic Fibrosis

Infectious Respiratory Conditions

Conductive Hearing Loss

Meniere Disease

Motion Sickness

Tinnitus

Ear Problems

Vertigo

Hearing Loss

Renal Cysts

Urinary Incontinence

Urinary Tract Infection

Bladder Disorder

Chronic Kidney Disease

Congenital Kidney Disease

Electrolyte Imbalance

Kidney Stones

Acute Pancreatitis

Diabetes

Hyperthyroidism

Hypothyroidism

Pituitary and Growth Disorder

Prostate Condition

Arthritis

Cardiovascular

Respiratory

Vision Problems

Vision Loss

Mental Health Issues

Surgical Pins or Wire

Insomnia

Other Medical Conditions

Other Diagnosed Diseases

Intake Consent (Review Required)

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