Clinical Intake (Short Version)
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Personal Info
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Contact Info
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Source of Referral
Address
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Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
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Taiwan, Province Of China
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Wallis And Futuna
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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
Health Questions
Low blood pressure
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Varicose veins
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Diabetes
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Meniere Disease
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Vertigo
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Asthma
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Epilepsy
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Migraines/Headaches
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Warts
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Blood thinner medication
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Gastrointestinal
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Mood Disorder
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Cancer
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Hearing Impairment
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Pacemaker
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Cardiovascular
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Heart Attack
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Past Heart Surgery
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Concussion
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Heart Condition
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Schizophrenia
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Congenital Heart Defect
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High blood pressure
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HIV/Aids
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Stroke
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Depression
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Energy Level
Chaotic
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Vibrant
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Clear
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Dull
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Even
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Fatigue
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Flat
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High
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Agitated
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Low
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Acupuncture
Arthritis
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Bursitis/Tendonitis
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Carpal Tunnel
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Cold Hands/Feet
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Fatigue
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Nerve Pain
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Numbness
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Sciatica
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Energy
Do you struggle with insomnia?
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Does your energy fluctuate?
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How long do you sleep on average?
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Is your energy constant?
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What is your energy level upon awakening?
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When is your energy highest?
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When is your energy lowest?
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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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Massage Goals
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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Improve Symptoms
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Increase Well-Being
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Injury Rehabilitation
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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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Physical Activities You Participate In
Baseball
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Pilates
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Waterpolo
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Basketball
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Rugby
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Weight Lifting
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Crossfit
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Running
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Yoga
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Football
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Soccer
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Golf
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Softball
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Hockey
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Swimming
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Lacrosse
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Tennis
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Marathon
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Triathlon
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Other Activities
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Emotion / Mood
PTSD
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Despair
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Fear
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Rate the stress in your life (1-10)
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Grief
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Sadness
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Mental Abuse History
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Stress Response and Coping Strategies
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Negative Self-Talk
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Anger
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Other Emotions
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Anxiety
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Overall mood and energy level
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Confusion
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Physical Abuse History
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Depression
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