Clinical Intake (Short Version)
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Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
Identify as
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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
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Bouvet Island
Brazil
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Bulgaria
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Central African Republic
Chad
Chile
China
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Cocos (Keeling) Islands
Colombia
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Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
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Denmark
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Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
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Iceland
India
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Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
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Jordan
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Kenya
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Korea, Democratic People'S Republic Of
Korea, Republic Of
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Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
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Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
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Malawi
Malaysia
Maldives
Mali
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Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
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Samoa
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Saudi Arabia
Senegal
Serbia
Seychelles
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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
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Tunisia
Turkey
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Tuvalu
Uganda
Ukraine
United Arab Emirates
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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
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
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Adjuster's Name
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Policy Number
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Office Address
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Unit #
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City
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Country
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Prov / State
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Postal Code / Zip
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Phone
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Fax
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Email Address
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Claims / Benefit
Conditions
Health Questions
Low blood pressure
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Varicose veins
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Diabetes
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Meniere Disease
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Vertigo
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Asthma
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Epilepsy
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Migraines/Headaches
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Warts
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Blood thinner medication
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Gastrointestinal
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Mood Disorder
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Cancer
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Hearing Impairment
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Pacemaker
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Cardiovascular
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Heart Attack
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Past Heart Surgery
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Concussion
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Heart Condition
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Schizophrenia
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Congenital Heart Defect
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High blood pressure
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HIV/Aids
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Stroke
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Depression
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Energy Level
Chaotic
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Vibrant
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Clear
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Dull
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Even
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Fatigue
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Flat
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High
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Agitated
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Low
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Acupuncture
Arthritis
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Bursitis/Tendonitis
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Carpal Tunnel
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Cold Hands/Feet
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Fatigue
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Nerve Pain
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Numbness
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Sciatica
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Energy
Do you struggle with insomnia?
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Does your energy fluctuate?
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How long do you sleep on average?
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Is your energy constant?
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What is your energy level upon awakening?
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When is your energy highest?
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When is your energy lowest?
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Headaches
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Massage Goals
Address Health Issues
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Pain Relief
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Alternative Therapy
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Positive Reinforcement
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Balance
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Strength Training
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Flexibility
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Stress Relief
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Improve Fitness
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Improve Symptoms
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Increase Well-Being
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Injury Rehabilitation
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Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Medium Pressure Preferred
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Other
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Deep Pressure Preferred
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Workers Comp Claim
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Crime Victim Comp.
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Physical Activities You Participate In
Baseball
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Pilates
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Waterpolo
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Basketball
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Rugby
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Weight Lifting
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Crossfit
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Running
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Yoga
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Football
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Soccer
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Golf
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Softball
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Hockey
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Swimming
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Lacrosse
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Tennis
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Marathon
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Triathlon
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Other Activities
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Emotion / Mood
PTSD
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Despair
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Fear
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Rate the stress in your life (1-10)
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Grief
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Sadness
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Mental Abuse History
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Stress Response and Coping Strategies
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Negative Self-Talk
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Anger
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Other Emotions
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Anxiety
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Overall mood and energy level
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Confusion
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Physical Abuse History
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Depression
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