Intake Form
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Personal Info
First Name
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Date of Birth (MM/DD/YYYY)
Gender
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Identify as
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Occupation
Contact Info
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Source of Referral
Address
City
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Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
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Algeria
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Anguilla
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Bouvet Island
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Heard Island And Mcdonald Islands
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Samoa
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Slovenia
Solomon Islands
Somalia
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South Georgia And The South Sandwich Islands
Spain
Sri Lanka
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Suriname
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Swaziland
Sweden
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Syrian Arab Republic
Taiwan, Province Of China
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Tanzania, United Republic Of
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Ukraine
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Uruguay
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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
Conditions
Treatment Goals
Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Other
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Massage Goals
Address Health Issues
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Strength Training
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Alternative Therapy
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Stress Relief
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Balance
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Flexibility
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Improve Fitness
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Increase Well-Being
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Injury Rehabilitation
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Positive Reinforcement
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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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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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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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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Allergy
Latex
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Medical
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Miscellaneous
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Environmental
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Food
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you been tested for COVID?
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Fever Over 100.4 degrees
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New Onset of Cough
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Sore Throat
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Shortness of Breath
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Difficulty Breathing
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Fatigue
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Chills
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Pink eye (conjunctivitis)
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Nasal or sinus congestion
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Runny nose/nasal congestion without other known cause
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Sudden onset body aches
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New rash or other skin changes
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Regular cardio exercise
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Contact with someone with COVID
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Contact with someone who was in contact with COVID
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Contact with anyone with acute respiratory Illness
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Recent travel to area with high infection rates
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Been in group where social distancing not observed
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Are you considered high risk?
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Spend time around anyone that is high risk
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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
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