Institute of Integrative Health Specialists and Holistic Wellness Center, LLC
Bodywork Therapy Intake Form
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Personal Info
First Name
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Occupation
Contact Info
Mobile Phone
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Source of Referral
Address
City
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Australia
Canada
Ireland
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United Kingdom
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Afghanistan
Albania
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Heard Island And Mcdonald Islands
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Madagascar
Malawi
Malaysia
Maldives
Mali
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Martinique
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Mexico
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Mongolia
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Netherlands
Netherlands Antilles
New Caledonia
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Nigeria
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Palestinian Territory, Occupied
Panama
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Portugal
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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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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
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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
Well Being
Sports
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Caffeine
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Drinking
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Exercise
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Flexibility
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Hobbies
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Interests
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Mobility/Walking Aids
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Range of Motion
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Changes to your medical history since initial intake?
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Willing to wash hands before entering clinic
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Willing to wash hands before leaving clinic
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Willing to sanitise hands when entering and leaving clinic
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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 tested positive for COVID-19?
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Have you been tested for COVID?
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Have you had the antibody test?
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Fever Over 100.4 degrees
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Fever Over 38 degrees
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Headaches
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What is your Temperature?
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New Onset of Cough
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Worsening Chronic Cough
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Sore Throat
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Difficulty Swallowing
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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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Have you had a new onset of muscle aches and pain since the emergence of the virus?
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Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
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Fatigue
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Chills
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If a child, purple markings on fingers and toes
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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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Nausea
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Vomiting
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Diarrhea
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Abdominal Pain
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Sudden onset body aches
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New rash or other skin changes
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Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
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Regular cardio exercise
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Can you exercise to get your heart rate up without any problem?
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Can you exercise to get your respiratory rate up without any problem?
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Contact with someone with COVID
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Had close contact with a confirmed case of COVID-19 without wearing PPE
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Are you in high or moderate risk groups?
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Have you been shielding?
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Contact with someone who is awaiting COVID test results.
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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 domestic air travel
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Recent international air travel
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Recent travel to area with high infection rates
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Recent travel outside your province within the past 14 days
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Did you travel outside of Canada in the past 14 days?
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In the past 2 weeks, have you or someone with whom you interact traveled outside the Atlantic Bubble?
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In the past 2 weeks, have you or someone with whom you interact traveled outside of Nova Scotia?
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In the past 2 weeks, have you or someone with whom you interact traveled to or from Halifax Regional Municipality?
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To the best of your knowledge, within the last 14 days has any member of your household or support bubble tested positive for COVID-19 or experienced any COVID-19 symptoms?
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To the best of your knowledge, within the last 14 days have you or any other member of your household or support bubble has been exposed to anyone diagnosed with COVID-19 or experiencing COVID?
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Within the last 14 days, have you tested positive for COVID-19 or experienced any COVID-19 symptoms?
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Have you travelled abroad in the last 14 days?
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Have you received a covid alert that you were in close contact with someone with covid, through the covid app in the last 14 days?
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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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If over 70, unexplained or increase number of falls?
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If over 70, acute functional decline?
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If over 70, worsening of chronic conditions?
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If over 70, symptoms of delirium?
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I agree to wear a clean disposable or reusable mask
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I agree to wash/sanitize my hands before and after treatment
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No COVID Symptoms
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Do you consent to me informing NHS Scotland Test & Protect of your details if either you or I find out we are infected?
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Do you consent to the consultation, assessment and treatment by the therapist?
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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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Migraines
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Rebound
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Sinus
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Tension
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Chronic Daily Headache
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Cluster
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Other Headaches
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Musculoskeletal
Ankylosing Spondylitis
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Scleroderma
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Chronic Fatigue Syndrome
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Torticollis
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Fracture
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Osgood-Schlatter Disease
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Arthritis
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Scoliosis
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Chronic Myofascial Pain Syndrome
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Whiplash
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Gout
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Osteoarthritis
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Artificial Joints / Special Equipment
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Sinus Problems
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Compartment Syndrome
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Hereditary/Congenital Deformity
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Osteomalacia
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Osteoporosis
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Baker's Cyst
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Spasms / Cramps
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Degenerative Disk Disease
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Jaw Pain (TMJD)
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Paget Disease
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Bone Disease
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Spondylolisthesis
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Dislocation
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Joint Injury
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Plantar Fasciitis
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Bone or Joint Disease
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Strain/Sprain
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Psoriatic Arthritis
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Broken Bone / Fracture
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Temporomandibular Joint Dysfunction
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Ehlers-Danlos Syndrome
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Muscular Dystrophy
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Adhesive Capsulitis
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Amyotrophic Lateral Sclerosis (ALS)
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Recti Diastasis
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Fibromyalgia
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Myasthenia Gravis
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Other Musculoskeletal
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Massage Goals
Improve Symptoms
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Increase Well-Being
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Injury Rehabilitation
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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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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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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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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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Allergy
Food
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Latex
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Mastocytosis
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MCAD
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Medical
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Miscellaneous
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Coconut Oil
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Sensitive to scents/essential oils
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Environmental
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Other Allergies
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Bodywork Client Forms + COVID-19 | Updated 10/24/21
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