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New Client Intake Form
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Contact Info
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Australia (+61)
Canada (+1)
Ireland (+353)
New Zealand (+64)
United Kingdom (+44)
United States (+1)
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Afghanistan
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Iraq
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Virgin Islands, U.S.
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Province / State
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Emergency Contact
Emergency Contact
Emergency Phone
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Other
Medical Info
What is your Primary Complaint? (or just say "relaxation")
Describe when and how the pain started.
What makes it worse?
Describe the pain (ache, sharp, stabbing, burning, numb, etc.)
Does the pain radiate (starts in one place and moves to another)?
On a scale of 1-10, what is your pain right now?
What time of day is the pain at its worse?
What have you done to try to make the pain better (meds, exercise, topicals, doctors)?
Current Treatment (on primary complaint)
Past Treatment (from other practitioners on primary complaint)
Medications, Vitamins/Herbs (include reason for taking)
Significant Injuries during lifetime (give year)
All Surgeries (give year)
Have you had SURGERY within the last 8 WEEKS? (Please provide a note from your doctor allowing us to work on you.)
Are you currently on a course of ANTIBIOTICS? (Please schedule you treatment after you have finished your antibiotic)
What is your Height & Weight?
How many ounces of plain water do you drink daily?
Have you had any recent injections, patches, pumps, or implants? Explain.
Do you have any allergies (skin or other)? Explain.
Do you have any upcoming medical procedures?
Yes
No
How were you referred to our office?
Conditions
Well Being
I do not speak English. I will bring an interpreter to stay with me at all times.
I use Mobility/Walking Aids. (Therapists cannot legally assist clients who are non-ambulatory.)
I smoke
I exercise regularly
I play sports.
Massage Goals
For injury rehabilitation
As an alternative therapy to...
For stress relief
For flexibility
To start on a regular massage plan
Other
All Areas 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
Which best describes what you are experiencing
Pain or tension or both?
Mild
Moderate
Disabling
Getting Worse
Staying the Same
Getting Better
Constant
Intermittent
Increases with Activity
Decreases with Activity
Other
Musculoskeletal
Broken Bone / Fracture
Osteoporosis
Dislocation
Scleroderma
Whiplash
Bone or Joint Disease
Ehlers-Danlos Syndrome
Fracture
Osteoarthritis
Scoliosis
Tendonitis/Bursitis
Joint Stiffness / Swelling
Gout
Hereditary/Congenital Deformity
Sinus Problems
Degenerative Disk Disease
Plantar Fasciitis
Strain/Sprain
Torticollis
Spasms / Cramps
Chronic Myofascial Pain Syndrome
Artificial Joints / Special Equipment
Joint Injury
Dupuytren's Contracture
Amyotrophic Lateral Sclerosis (ALS)
Baker's Cyst
Chronic Fatigue Syndrome
Osgood-Schlatter Disease
Muscular Dystrophy
Recti Diastasis
Arthritis
Ankylosing Spondylitis
Osteomalacia
Fibromyalgia
Myasthenia Gravis
Carpal Tunnel Syndrome
Jaw Pain (TMJD)
Bone Disease
Paget Disease
Spondylolisthesis
Compartment Syndrome
Temporomandibular Joint Dysfunction
Psoriatic Arthritis
Other Musculoskeletal
Neurological
Stabbing
Loss of Sensation
Brain Disorder
Bell's Palsy
Chiari Malformation
Sleeping Disorders
Sciatic Pain
Chronic Pain Disorder
Peripheral Neuropathy
Syringomyelia
Carpal Tunnel
Post Polio Syndrome
Brain Injury
Tethered Cord
Stroke
Epilepsy
Cerebral Vascular Accident (Stroke)
Cerebrospinal Fluid Leak
Fibromyalgia
Seizure Disorder
Shingles
Dural Ectasia
Cerebral Palsy
Shingles / Herpes
Transient Ischemic Attacks (TIA)
Dizziness
Parkinsons
Numbness
Vertebral and Spinal Cord Injury
Twitching of Face
Herniated Disc
Burning
Tingling
Huntington Disease
Fatigue
Cerebral-vascular Accident
Multiple Sclerosis
Other Neurological
Skin
Hypersensitive Reaction
Non-Surgical Scars
Plantar's Wart
Bruise Easily
Acne
Surgical Scars
Psoriasis
Allergic Dermatosis
Herpes
Rash
Moles
Athletes Foot
Melanoma
Rosacea
Cosmetic Surgery
Chemical Burn
UV Burn
Severe Irritability
Hypersensitive Reactions
Skin Conditions
Infectious Skin Conditions
Melanoma/Carcinoma
Skin Irritations
Eczema
Athlete's Foot
Pigmentary Disorder
Allergic to Iodine
Combination Skin
Dry Skin
Oily Skin
Mature Skin
Sensitive Skin
Sun Damage
Using ALPHA Hydroxy Acids
Using RETIN A
Other Skin
Prenatal or POSTNATAL
I have had a baby within the last 8 weeks. (Please provide a doctor's note giving us permission to treat you prior to 8 weeks post-delivery.)
Due Date (currently pregnant)
I will present MassageFIX with a referral from my OBGYN. (Midwife/Doula referrals cannot be accepted at this time.)
Trimester
Weeks Pregnant
Number of previous pregnancies/births?
Edema/Swelling
Leg Cramps
Miscarriage (Please allow 8 weeks post-miscarriage before any massage.)
Nausea
Sciatica
Previous C-Section
High Risk Pregnancy (MassageFIX will not accept high risk pregnancy clients until 8 weeks post delivery.)
Cardiovascular
Blood Clots
Chronic Ischemic Heart Disease
Stroke
Heart Attack
Valve Disorders
Lymphedema
Chronic Venous Insufficiency
Fainting Spells
Phlebitis
Peripheral Vascular Disease
Congenital Heart Defect
Cardiovascular Accident
Acute Coronary Syndrome
Coronary Artery Disease
Cold Hands
Pacemaker
Aneurysm
Hyperlipidemia
Cold Feet
Heart Disease
Myocardial infarction
Postural Orthostatic Tachycardia Syndrome
Angina
High Blood Pressure
Pericarditis
Varicose Veins
Atherosclerosis
Chest Pain
Low Blood Pressure
Raynaud Disease
Cardiovascular Conditions
Swelling
Cardiac Arrhythmia
Heart Condition
Congestive Heart Failure
Blood Pressure
Rheumatic Heart Disease
Other Cardiovascular
Headaches
Chronic Daily Headache
Tension
Migraines
Headaches
Cluster
Rebound
Sinus
Other Headaches
TMJ (Jaw)
Ear Stuffiness
Ear Pressure
Jaw Pain
Ear Blockage
Grinding
Clicking
Locking
Difficulty Opening Jaw
Difficulty Chewing
Clenching
Morning Stiffness
Ear Ringing
Feet
Previous Amputations
Onychocryptosis (Ingrown Nail)
Pes Planus (Flat Feet)
Pes Cavus (High Arch)
Bunions
Itchy or Peeling Skin
Onychoptosis (Nail Loss)
Onychomycosis (Nail Fungus)
Hallux Valgus
Emotion / Memory
Anxiety Disorder
Mood Disorder
Schizophrenia
Substance Use Disorder
Stress
Alzheimer Disease
Brain Disorders
Social Anxiety Disorder
ADD
Depression
ADHD
Generalized Anxiety Disorder
Autism
Obsessive Compulsive Disorder
Asperger Syndrome
Obsessive Compulsive Personality Disorder
Acute Stress Disorder
Bipolar Disorder
Panic Disorder
Agoraphobia
Borderline Personality Disorder
PTSD
Anorexia Nervosa
Bulimia Nervosa
Schizophrenia
Sleep Disorder
Antisocial Personality Disorder
Claustrophobia
Oncology
Cancer Type
Date of Diagnosis
Location
Status
Treatment: Surgery
Date of Surgery
Lymph Nodes Removed
Side Effects of Surgery
Reconstruction Date
Treatment: Chemotherapy
Number of Chemo Treatments
Side Effects of Chemo
Treatment: Radiation
Number of Radiation Treatments
Area of Radiation
Nodes Irradiated
Side Effects of Radiation
Other Treatments
Medical Devices
Mouth Sores
Weight Loss
Weight Gain
Adhesions
Incision
Pressure Sensitivity
Pain
Former Injuries
Loss of Movement
Abnormal Skin Sensation
Memory Problems
Edema
Low Platelet
Low White Count
Excessively Warm/Cold
Dry Skin
Fragile Skin
Radiation Skin Reaction
Hair Loss
Fatigue
Current Tumour
Female Health
Menopause
Hysterectomy
Breast Cancer
Ovarian Cancer
Osteoporosis
Currently Pregnant (present OBGYN referral. Midwife/Doula referrals cannot be accepted at this time.)
Implants
Scar Tissue
Kidney
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Other Kidney
Immune
Sjogren's Syndrome
Infectious Mononucleosis
Leukemia
Allergies
Non-Hodgkin Lymphoma
Rheumatoid Arthritis
Anaphylaxis
Lupus
Cancer
HIV/Aids
Hodgkin Lymphoma
Other Immune
Respiratory
Cystic Fibrosis
Chronic Cough
Shortness of Breath
Tuberculosis
Sinus Problem
Asthma
Emphysema
Bronchitis
Respiratory Tract Infection
Respiratory Conditions
COPD
Infectious Respiratory Conditions
Other Respiratory
Blood
Hepatitis
HIV
Thrombosis/Embolism
High Cholesterol
Blood Thinner Medication
Anemia
Stroke
Bleeding Disorder
Fainting Spells
HIV/AIDS
Haemophilia
Other Blood
Endocrine
Pituitary and Growth Disorder
Diabetes
Adrenal Fatigue
Prostate Condition
Acute Pancreatitis
Hyperthyroidism
Temiskaming Diabetes Program
Hypothyroidism
Blood Sugar Managed?
Wound Healing Status?
Other Endocrine
Gastrointestinal
Crohn's Disease
Intestinal Polyps
Celiac Disease
Irritable Bowel Syndrome
Constipation
Abdominal Hernia
Poor Appetite
Diarrhea
Acid Reflux
Stomach Disorder
Diverticulitis
Hiatal Hernia
Ulcerative Colitis
Eating Disorder
Stomach Disorders
Digestive Conditions
Gastroparesis
Esophageal Disorder
Intestinal Gas/Bloating
Fecal Impaction
Other Gastrointestinal
Hearing
Conductive Hearing Loss
Meniere Disease
Motion Sickness
Ear Problems
Tinnitus
Hearing Loss
Vertigo
Other Hearing
Miscellaneous
Vision Problems
Loss of Balance
Vision Loss
Mental Health Issues
Surgical Pins or Wire
Upper Respiratory Infection
Insomnia
Weakened Immune Function
Liver Disease
ADHD
Contact Lens
Autism
Dentures
Hearing Impaired
Visually Impaired
Other Medical Conditions
Other Diagnosed Diseases
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