New Client Intake Form

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Mobile Phone

Home Phone

Work Phone

Source of Referral

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

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

How were you referred to our office?

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.

For injury rehabilitation

As an alternative therapy to...

For stress relief

For flexibility

To start on a regular massage plan

Other

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

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

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

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

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.)

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

Chronic Daily Headache

Tension

Migraines

Headaches

Cluster

Rebound

Sinus

Other Headaches

Ear Stuffiness

Ear Pressure

Jaw Pain

Ear Blockage

Grinding

Clicking

Locking

Difficulty Opening Jaw

Difficulty Chewing

Clenching

Morning Stiffness

Ear Ringing

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

Anxiety Disorder

Mood Disorder

Schizophrenia

Substance Use Disorder

Stress

Alzheimer Disease

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

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

Menopause

Hysterectomy

Breast Cancer

Ovarian Cancer

Osteoporosis

Currently Pregnant (present OBGYN referral. Midwife/Doula referrals cannot be accepted at this time.)

Implants

Scar Tissue

Electrolyte Imbalance

Kidney Stones

Renal Cysts

Urinary Incontinence

Urinary Tract Infection

Bladder Disorder

Chronic Kidney Disease

Congenital Kidney Disease

Other Kidney

Sjogren's Syndrome

Infectious Mononucleosis

Leukemia

Allergies

Non-Hodgkin Lymphoma

Rheumatoid Arthritis

Anaphylaxis

Lupus

Cancer

HIV/Aids

Hodgkin Lymphoma

Other Immune

Cystic Fibrosis

Chronic Cough

Shortness of Breath

Tuberculosis

Sinus Problem

Asthma

Emphysema

Bronchitis

Respiratory Tract Infection

Respiratory Conditions

COPD

Infectious Respiratory Conditions

Other Respiratory

Hepatitis

HIV

Thrombosis/Embolism

High Cholesterol

Blood Thinner Medication

Anemia

Stroke

Bleeding Disorder

Fainting Spells

HIV/AIDS

Haemophilia

Other Blood

Pituitary and Growth Disorder

Diabetes

Adrenal Fatigue

Prostate Condition

Acute Pancreatitis

Hyperthyroidism

Temiskaming Diabetes Program

Hypothyroidism

Blood Sugar Managed?

Wound Healing Status?

Other Endocrine

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

Conductive Hearing Loss

Meniere Disease

Motion Sickness

Ear Problems

Tinnitus

Hearing Loss

Vertigo

Other Hearing

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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