Need Help? Call:
520-326-8300
Rooted Integrative Wellness Massage Therapy Intake
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
Conditions/Health History
Area of Complaint
Left Side of Neck
Right Side of Neck
Left Side of Upper Back
Right Side of Upper Back
Left Side of Mid Back
Right Side of Mid 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
Right Leg
Left Hip
Right Hip
Left Knee
Right Knee
Left Ankle
Right Ankle
Left Foot
Right Foot
Headaches
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Neurological
Tingling
Multiple Sclerosis
Brain Injury
Stabbing
Cerebral-vascular Accident
Cerebral Vascular Accident (Stroke)
Sciatic Pain
Loss of Sensation
Seizure Disorder
Stroke
Transient Ischemic Attacks (TIA)
Vertebral and Spinal Cord Injury
Epilepsy
Shingles
Cerebral Palsy
Huntington Disease
Dizziness
Parkinsons
Numbness
Burning
Herniated Disc
Chronic Pain Disorder
Cardiovascular
Cardiovascular Conditions
Congenital Heart Defect
Varicose Veins
Heart Attack
Blood Pressure
Acute Coronary Syndrome
Coronary Artery Disease
Blood Clots
Phlebitis
Aneurysm
Hyperlipidemia
Lymphedema
Cardiovascular Accident
Angina
Pericarditis
Pacemaker
Atherosclerosis
Raynaud Disease
Cold Hands
Heart Disease
Cardiac Arrhythmia
Rheumatic Heart Disease
High Blood Pressure
Cold Feet
Chronic Ischemic Heart Disease
Valve Disorders
Low Blood Pressure
Chronic Venous Insufficiency
Myocardial infarction
Congestive Heart Failure
Reproductive
Ovarian Cysts/Tumors
Pelvic Inflammatory Disease
Pregnancy
Gynaecological Conditions
Endometriosis
Immune
Non-Hodgkin Lymphoma
Rheumatoid Arthritis
Anaphylaxis
Allergies
Lupus
Hodgkin Lymphoma
Infectious Mononucleosis
Cancer
Leukemia
Musculoskeletal
Hereditary/Congenital Deformity
Strain/Sprain
Joint Injury
Amyotrophic Lateral Sclerosis (ALS)
Osgood-Schlatter Disease
Osteoporosis
Muscular Dystrophy
Osteoarthritis
Ankylosing Spondylitis
Gout
Osteomalacia
Myasthenia Gravis
Tendonitis/Bursitis
Bone Disease
Paget Disease
Sinus Problems
Compartment Syndrome
Psoriatic Arthritis
Artificial Joints / Special Equipment
Dislocation
Scleroderma
Fibromyalgia
Fracture
Arthritis
Jaw Pain (TMJD)
Scoliosis
Gastrointestinal
Constipation
Poor Appetite
Diarrhea
Crohn's Disease
Diverticulitis
Ulcerative Colitis
Eating Disorder
Celiac Disease
Irritable Bowel Syndrome
Blood
Hepatitis
Polycythemia
Haemophilia
HIV
Thrombosis/Embolism
High Cholesterol
Anemia
Bleeding Disorder
HIV/AIDS
Skin
Athlete's Foot
Psoriasis
Allergic Dermatosis
Rash
Bruise Easily
Melanoma
Melanoma/Carcinoma
Infectious Skin Conditions
Respiratory
Chronic Cough
Shortness of Breath
Asthma
Tuberculosis
Emphysema
Bronchitis
COPD
Cystic Fibrosis
Infectious Respiratory Conditions
Hearing
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Hearing Loss
Kidney
Renal Cysts
Urinary Incontinence
Chronic Kidney Disease
Congenital Kidney Disease
Kidney Stones
Endocrine
Acute Pancreatitis
Diabetes
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Family History
Arthritis
Cardiovascular
Respiratory
Miscellaneous
Vision Problems
Vision Loss
Surgical Pins or Wire
Insomnia
Other Medical Conditions
Other Diagnosed Diseases
Medications
Medication
Add Another Medication
Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
Review & Agree
Rooted Integrative Wellness Policies and Agreements
(Review Required)
You need to review and accept this before submitting
Signature
×
Submit Form
×