Amazing Hands Client Intake
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Uganda
Ukraine
United Arab Emirates
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Uruguay
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Venezuela, Bolivarian Republic Of
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Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
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Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Exercise
What arecyour exercise routines and frequencies
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Training (goal/outcome/program/etc)
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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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Medical massage?
Are you visiting for a medical massage?
Yes
No
I don't know
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)
We're you referred by a physician? (Name & number)
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Do you have a prescription/written referral
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Do you have diagnosis (include 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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Medications
Medication
Add Another Medication
Conditions
Addiction
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Allergies/Sensitive to perfumes, lotions, or oils
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Accident
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AIDS/HIV
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Arthritis
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Asthma
Back/Neck Issues
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Blood Clots
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Broken Bones
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Bruise Easily
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Cancer
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Circulation Problems
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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
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Hepatitis
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High / Low BP
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Mental / Emotional Distress / PTSD (Triggers in massage?)
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Mononucleosis
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Osteoporosis
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Pregnant/Trying
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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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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)
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Surgeries
Surgery
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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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Injuries
Injury
Add Another Injury
Insurance
I have insurance
Insurer
VA CCN Optum
Policy Name
Policy Holder
I'm not the policy holder.
First Name
Last Name
Relationship To Patient
Child
Parent
Spouse
Common Law Spouse
Other
Date of Birth
Address
City
Prov / State
Postal / Zip Code
Phone Number
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