Intake Form (2020)
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia (+61)
Canada (+1)
Ireland (+353)
New Zealand (+64)
United Kingdom (+44)
United States (+1)
------------
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
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
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
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
Characters:
0
/255
General Health
Characters:
0
/255
Current Treatment
Characters:
0
/255
Past Treatment (from other practitioners)
Characters:
0
/255
Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
Characters:
0
/255
Adjuster's Name
Characters:
0
/255
Policy Number
Characters:
0
/255
Office Address
Characters:
0
/255
Unit #
Characters:
0
/255
City
Characters:
0
/255
Country
Characters:
0
/255
Prov / State
Characters:
0
/255
Postal Code / Zip
Characters:
0
/255
Phone
Characters:
0
/255
Fax
Characters:
0
/255
Email Address
Characters:
0
/255
Claims / Benefit
Conditions
TMJ (Jaw)
Clicking
Characters:
0
/255
Jaw Pain
Characters:
0
/255
Difficulty Chewing
Characters:
0
/255
Locking
Characters:
0
/255
Difficulty Opening Jaw
Characters:
0
/255
Morning Stiffness
Characters:
0
/255
Ear Blockage
Characters:
0
/255
Ear Pressure
Characters:
0
/255
Ear Ringing
Characters:
0
/255
Ear Stuffiness
Characters:
0
/255
Clenching
Characters:
0
/255
Grinding
Characters:
0
/255
Health Questions
Concussion
Characters:
0
/255
COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
Characters:
0
/255
Willing to wash hands before leaving clinic
Characters:
0
/255
Willing to wear face mask in the clinic
Characters:
0
/255
Agree to wear face mask during treatment
Characters:
0
/255
Have you taken precautions to limit exposure
Characters:
0
/255
Have you been tested for COVID?
Characters:
0
/255
Have you had the antibody test?
Characters:
0
/255
Fever Over 100.4 degrees
Characters:
0
/255
Fever Over 38 degrees
Characters:
0
/255
New Onset of Cough
Characters:
0
/255
Sore Throat
Characters:
0
/255
Shortness of Breath
Characters:
0
/255
Persistent Pain in Chest
Characters:
0
/255
Decrease or sudden loss of taste and smell
Characters:
0
/255
Fatigue
Characters:
0
/255
Chills
Characters:
0
/255
Nasal or sinus congestion
Characters:
0
/255
Sudden onset body aches
Characters:
0
/255
New rash or other skin changes
Characters:
0
/255
Regular cardio exercise
Characters:
0
/255
Contact with someone with COVID
Characters:
0
/255
Contact with someone who was in contact with COVID
Characters:
0
/255
Recent domestic air travel
Characters:
0
/255
Recent international air travel
Characters:
0
/255
Recent travel to area with high infection rates
Characters:
0
/255
Been in group where social distancing not observed
Characters:
0
/255
Are you considered high risk?
Characters:
0
/255
Spend time around anyone that is high risk
Characters:
0
/255
Oncology
Cancer Type
Characters:
0
/255
Date of Diagnosis
Characters:
0
/255
Status
Characters:
0
/255
Area of Complaint
Neck
Characters:
0
/255
Left Side of Neck
Characters:
0
/255
Right Side of Neck
Characters:
0
/255
Upper Back
Characters:
0
/255
Left Side of Upper Back
Characters:
0
/255
Right Side of Upper Back
Characters:
0
/255
Mid Back
Characters:
0
/255
Left Side of Mid Back
Characters:
0
/255
Right Side of Mid Back
Characters:
0
/255
Low Back
Characters:
0
/255
Left Side of Low Back
Characters:
0
/255
Right Side of Low Back
Characters:
0
/255
Chest
Characters:
0
/255
Abdomen
Characters:
0
/255
Left Arm
Characters:
0
/255
Right Arm
Characters:
0
/255
Left Shoulder
Characters:
0
/255
Right Shoulder
Characters:
0
/255
Left Elbow
Characters:
0
/255
Right Elbow
Characters:
0
/255
Left Wrist
Characters:
0
/255
Right Wrist
Characters:
0
/255
Left Hand
Characters:
0
/255
Right Hand
Characters:
0
/255
Left Leg
Characters:
0
/255
Left Thigh
Characters:
0
/255
Left Calf
Characters:
0
/255
Right Leg
Characters:
0
/255
Right Thigh
Characters:
0
/255
Right Calf
Characters:
0
/255
Left Gluteal
Characters:
0
/255
Right Gluteal
Characters:
0
/255
Left Hip
Characters:
0
/255
Right Hip
Characters:
0
/255
Left Groin
Characters:
0
/255
Right Groin
Characters:
0
/255
Left Knee
Characters:
0
/255
Right Knee
Characters:
0
/255
Left Ankle
Characters:
0
/255
Right Ankle
Characters:
0
/255
Left Foot
Characters:
0
/255
Right Foot
Characters:
0
/255
Sacrum
Characters:
0
/255
Tailbone (coccyx)
Characters:
0
/255
Headaches
Cluster
Characters:
0
/255
Headaches
Characters:
0
/255
Migraines
Characters:
0
/255
Rebound
Characters:
0
/255
Sinus
Characters:
0
/255
Tension
Characters:
0
/255
Chronic Daily Headache
Characters:
0
/255
Other Headaches
Characters:
0
/255
Musculoskeletal
Arthritis
Characters:
0
/255
Scoliosis
Characters:
0
/255
Baker's Cyst
Characters:
0
/255
Carpal Tunnel Syndrome
Characters:
0
/255
Degenerative Disk Disease
Characters:
0
/255
Fibromyalgia
Characters:
0
/255
Osteoarthritis
Characters:
0
/255
Osteoporosis
Characters:
0
/255
Plantar Fasciitis
Characters:
0
/255
Other Musculoskeletal
Characters:
0
/255
Skin
Plantar's Wart
Characters:
0
/255
Skin Conditions
Characters:
0
/255
Athlete's Foot
Characters:
0
/255
Bruise Easily
Characters:
0
/255
Herpes
Characters:
0
/255
Other Skin
Characters:
0
/255
Cardiovascular
Phlebitis
Characters:
0
/255
Varicose Veins
Characters:
0
/255
Angina
Characters:
0
/255
Congestive Heart Failure
Characters:
0
/255
Heart Attack
Characters:
0
/255
Heart Disease
Characters:
0
/255
High Blood Pressure
Characters:
0
/255
Low Blood Pressure
Characters:
0
/255
Pacemaker
Characters:
0
/255
Other Cardiovascular
Characters:
0
/255
Family History
Cancer
Characters:
0
/255
Cardiovascular
Characters:
0
/255
Diabetes
Characters:
0
/255
Respiratory
Characters:
0
/255
Arthritis
Characters:
0
/255
Neurological
Stroke
Characters:
0
/255
Transient Ischemic Attacks (TIA)
Characters:
0
/255
Bell's Palsy
Characters:
0
/255
Cerebral Vascular Accident (Stroke)
Characters:
0
/255
Epilepsy
Characters:
0
/255
Loss of Sensation
Characters:
0
/255
Sciatic Pain
Characters:
0
/255
Shingles
Characters:
0
/255
Other Neurological
Characters:
0
/255
Blood
Anemia
Characters:
0
/255
Bleeding Disorder
Characters:
0
/255
Fainting Spells
Characters:
0
/255
Haemophilia
Characters:
0
/255
Hepatitis
Characters:
0
/255
High Cholesterol
Characters:
0
/255
HIV/AIDS
Characters:
0
/255
Stroke
Characters:
0
/255
Other Blood
Characters:
0
/255
Respiratory
Chronic Cough
Characters:
0
/255
Emphysema
Characters:
0
/255
Shortness of Breath
Characters:
0
/255
Tuberculosis
Characters:
0
/255
Asthma
Characters:
0
/255
Bronchitis
Characters:
0
/255
Other Respiratory
Characters:
0
/255
Hearing
Hearing Loss
Characters:
0
/255
Tinnitus
Characters:
0
/255
Vertigo
Characters:
0
/255
Other Hearing
Characters:
0
/255
Endocrine
Diabetes
Characters:
0
/255
Hyperthyroidism
Characters:
0
/255
Hypothyroidism
Characters:
0
/255
Other Endocrine
Characters:
0
/255
Reproductive
Gynaecological Conditions
Characters:
0
/255
Pregnancy
Characters:
0
/255
Other Reproductive
Characters:
0
/255
Gastrointestinal
Celiac Disease
Characters:
0
/255
Constipation
Characters:
0
/255
Crohn's Disease
Characters:
0
/255
Digestive Conditions
Characters:
0
/255
Other Gastrointestinal
Characters:
0
/255
Immune
Allergies
Characters:
0
/255
Anaphylaxis
Characters:
0
/255
Other Immune
Characters:
0
/255
Miscellaneous
Mental Health Issues
Characters:
0
/255
Surgical Pins or Wire
Characters:
0
/255
Vision Loss
Characters:
0
/255
Vision Problems
Characters:
0
/255
Other Medical Conditions
Characters:
0
/255
Other Diagnosed Diseases
Characters:
0
/255
Prenatal (check boxes to enter details below)
Due Date
Characters:
0
/255
Trimester
Characters:
0
/255
Weeks Pregnant
Characters:
0
/255
Number of previous pregnancies/births?
Characters:
0
/255
Massage Goals
Stress Relief
Characters:
0
/255
Address Health Issues
Characters:
0
/255
Alternative Therapy
Characters:
0
/255
Balance
Characters:
0
/255
Flexibility
Characters:
0
/255
Improve Fitness
Characters:
0
/255
Increase Well-Being
Characters:
0
/255
Injury Rehabilitation
Characters:
0
/255
Date of Last Massage
Characters:
0
/255
Massage Frequency
Characters:
0
/255
Other
Characters:
0
/255
Review & Agree
Privacy Policy/Consent Form
You need to accept this before submitting
Signature
×
Submit Form
×