Intake Form (2020)
Personal Info
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Last Name
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Occupation
Contact Info
Mobile Phone
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City
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Australia (+61)
Canada (+1)
Ireland (+353)
New Zealand (+64)
United Kingdom (+44)
United States (+1)
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
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Korea, Republic Of
Kuwait
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Macedonia, The Former Yugoslav Republic Of
Madagascar
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Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
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Morocco
Mozambique
Myanmar
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Netherlands
Netherlands Antilles
New Caledonia
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Niger
Nigeria
Niue
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Northern Mariana Islands
Norway
Oman
Pakistan
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Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
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
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Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
General Health
Current Treatment
Past Treatment (from other practitioners)
Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
Adjuster's Name
Policy Number
Office Address
Unit #
City
Country
Prov / State
Postal Code / Zip
Phone
Fax
Email Address
Claims / Benefit
Conditions
TMJ (Jaw)
Clicking
Jaw Pain
Difficulty Chewing
Locking
Difficulty Opening Jaw
Morning Stiffness
Ear Blockage
Ear Pressure
Ear Ringing
Ear Stuffiness
Clenching
Grinding
Health Questions
Concussion
COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
Willing to wash hands before leaving clinic
Willing to wear face mask in the clinic
Agree to wear face mask during treatment
Have you taken precautions to limit exposure
Have you been tested for COVID?
Have you had the antibody test?
Fever Over 100.4 degrees
Fever Over 38 degrees
New Onset of Cough
Sore Throat
Shortness of Breath
Persistent Pain in Chest
Decrease or sudden loss of taste and smell
Fatigue
Chills
Nasal or sinus congestion
Sudden onset body aches
New rash or other skin changes
Regular cardio exercise
Contact with someone with COVID
Contact with someone who was in contact with COVID
Recent domestic air travel
Recent international air travel
Recent travel to area with high infection rates
Been in group where social distancing not observed
Are you considered high risk?
Spend time around anyone that is high risk
Oncology
Cancer Type
Date of Diagnosis
Status
Area of Complaint
Neck
Left Side of Neck
Right Side of Neck
Upper Back
Left Side of Upper Back
Right Side of Upper Back
Mid Back
Left Side of Mid Back
Right Side of Mid Back
Low 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
Left Thigh
Left Calf
Right Leg
Right Thigh
Right Calf
Left Gluteal
Right Gluteal
Left Hip
Right Hip
Left Groin
Right Groin
Left Knee
Right Knee
Left Ankle
Right Ankle
Left Foot
Right Foot
Sacrum
Tailbone (coccyx)
Headaches
Cluster
Headaches
Migraines
Rebound
Sinus
Tension
Chronic Daily Headache
Other Headaches
Musculoskeletal
Arthritis
Scoliosis
Baker's Cyst
Carpal Tunnel Syndrome
Degenerative Disk Disease
Fibromyalgia
Osteoarthritis
Osteoporosis
Plantar Fasciitis
Other Musculoskeletal
Skin
Plantar's Wart
Skin Conditions
Athlete's Foot
Bruise Easily
Herpes
Other Skin
Cardiovascular
Phlebitis
Varicose Veins
Angina
Congestive Heart Failure
Heart Attack
Heart Disease
High Blood Pressure
Low Blood Pressure
Pacemaker
Other Cardiovascular
Family History
Cancer
Cardiovascular
Diabetes
Respiratory
Arthritis
Neurological
Stroke
Transient Ischemic Attacks (TIA)
Bell's Palsy
Cerebral Vascular Accident (Stroke)
Epilepsy
Loss of Sensation
Sciatic Pain
Shingles
Other Neurological
Blood
Anemia
Bleeding Disorder
Fainting Spells
Haemophilia
Hepatitis
High Cholesterol
HIV/AIDS
Stroke
Other Blood
Respiratory
Chronic Cough
Emphysema
Shortness of Breath
Tuberculosis
Asthma
Bronchitis
Other Respiratory
Hearing
Hearing Loss
Tinnitus
Vertigo
Other Hearing
Endocrine
Diabetes
Hyperthyroidism
Hypothyroidism
Other Endocrine
Reproductive
Gynaecological Conditions
Pregnancy
Other Reproductive
Gastrointestinal
Celiac Disease
Constipation
Crohn's Disease
Digestive Conditions
Other Gastrointestinal
Immune
Allergies
Anaphylaxis
Other Immune
Miscellaneous
Mental Health Issues
Surgical Pins or Wire
Vision Loss
Vision Problems
Other Medical Conditions
Other Diagnosed Diseases
Prenatal (check boxes to enter details below)
Due Date
Trimester
Weeks Pregnant
Number of previous pregnancies/births?
Massage Goals
Stress Relief
Address Health Issues
Alternative Therapy
Balance
Flexibility
Improve Fitness
Increase Well-Being
Injury Rehabilitation
Date of Last Massage
Massage Frequency
Other
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