Intake Form (2020)
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
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Occupation
Contact Info
Mobile Phone
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Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
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Botswana
Bouvet Island
Brazil
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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
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Equatorial Guinea
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Faroe Islands
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Gabon
Gambia
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Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
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India
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Iran, Islamic Republic Of
Iraq
Isle Of Man
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Lao People'S Democratic Republic
Latvia
Lebanon
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Liechtenstein
Lithuania
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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
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Netherlands
Netherlands Antilles
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Nigeria
Niue
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Northern Mariana Islands
Norway
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Panama
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Paraguay
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Poland
Portugal
Puerto Rico
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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
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
Conditions
Feet
Thickened Nails
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Hallux Valgus
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Onychomycosis (Nail Fungus)
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Yellow Nails
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Hammer Toe
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Onychoptosis (Nail Loss)
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Heel Fissures
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Overlapping Toes
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Involuted Nails (Curved/Pinched)
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Pes Cavus (High Arch)
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Bunions
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Itchy or Peeling Skin
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Pes Planus (Flat Feet)
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Claw Toe
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Mallet Toe
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Plantar Fasciitis
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Corns/Callouses
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Onychauxis
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Plantar Wart
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Previous Amputations
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Dry/Cracked Skin
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Onychocryptosis (Ingrown Nail)
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TMJ (Jaw)
Clenching
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Grinding
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Clicking
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Jaw Pain
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Difficulty Chewing
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Locking
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Difficulty Opening Jaw
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Morning Stiffness
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Ear Blockage
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Ear Pressure
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Ear Ringing
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Ear Stuffiness
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Health Questions
Heart Attack
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Vertigo
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Heart Condition
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Meniere Disease
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Asthma
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Mood Disorder
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Concussion
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Pacemaker
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Congenital Heart Defect
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Past Heart Surgery
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Depression
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Schizophrenia
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Epilepsy
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Hearing Impairment
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Stroke
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Treatment Goals
Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Other
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Well Being
Caffeine
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Smoking
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Drinking
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Sports
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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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Emotion / Memory
Mood Disorder
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Schizophrenia
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Stress
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Substance Use Disorder
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Alzheimer Disease
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Anxiety Disorder
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Infectious
Epstein Barr
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Lyme Disease
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Pneumonia
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Strep
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Side Effects of Surgery
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Reconstruction Date
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Treatment: Chemotherapy
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Number of Chemo Treatments
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Area of Radiation
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Nodes Irradiated
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Side Effects of Radiation
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Other Treatments
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Medical Devices
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Nausea
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Vomiting
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Mouth Sores
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Weight Loss
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Weight Gain
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Bone Pain
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Adhesions
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Incision
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Pressure Sensitivity
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Pain
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Former Injuries
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Loss of Movement
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Abnormal Skin Sensation
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Memory Problems
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Edema
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Low Platelet
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Low White Count
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Blood Clot
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Excessively Warm/Cold
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Lymphedema
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Heart Condition
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Lung Condition
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Dry Skin
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Fragile Skin
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Radiation Skin Reaction
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Hair Loss
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Fatigue
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Systemic Infection
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Infectious Condition
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Current Tumour
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Enlarged Lymph Nodes
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Enlarged Spleen
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Enlarged Liver
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Radioactivity
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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
Cluster
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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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Other Headaches
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Brain Disorders
Antisocial Personality Disorder
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Generalized Anxiety Disorder
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Asperger Syndrome
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Obsessive Compulsive Disorder
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Autism
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Obsessive Compulsive Personality Disorder
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Acute Stress Disorder
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Bipolar Disorder
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Panic Disorder
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ADD
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Borderline Personality Disorder
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PTSD
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ADHD
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Bulimia Nervosa
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Schizophrenia
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Agoraphobia
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Claustrophobia
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Sleep Disorder
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Social Anxiety Disorder
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Anorexia Nervosa
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Depression
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Cardiovascular
Phlebitis
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Cardiac Arrhythmia
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Cold Hands
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High Blood Pressure
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Postural Orthostatic Tachycardia Syndrome
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Cardiovascular Accident
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Congenital Heart Defect
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Hyperlipidemia
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Raynaud Disease
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Cardiovascular Conditions
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Congestive Heart Failure
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Low Blood Pressure
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Acute Coronary Syndrome
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Aneurysm
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Rheumatic Heart Disease
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Chest Pain
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Coronary Artery Disease
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Lymphedema
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Angina
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Stroke
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Chronic Ischemic Heart Disease
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Fainting Spells
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Myocardial infarction
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Atherosclerosis
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Swelling
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Chronic Venous Insufficiency
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Heart Attack
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Pacemaker
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Blood Clots
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Valve Disorders
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Cold Feet
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Heart Condition
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Pericarditis
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Peripheral Vascular Disease
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Blood Pressure
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Varicose Veins
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Heart Disease
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Other Cardiovascular
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Skin
Rosacea
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Chemical Burn
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Melanoma
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Severe Irritability
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Cosmetic Surgery
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Melanoma/Carcinoma
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Skin Conditions
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Dermatographia
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Moles
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Skin Irritations
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Acne
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Eczema
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Non-Surgical Scars
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Surgical Scars
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Allergic Dermatosis
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Herpes
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Pigmentary Disorder
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Urticaria
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Athlete's Foot
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Hypersensitive Reaction
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Plantar's Wart
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Psoriasis
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UV Burn
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Athletes Foot
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Hypersensitive Reactions
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Rash
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Bruise Easily
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Infectious Skin Conditions
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Allergic to Iodine
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Combination Skin
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Dry Skin
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Oily Skin
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Mature Skin
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Sensitive Skin
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Sun Damage
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Using ALPHA Hydroxy Acids
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Using RETIN A
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Other Skin
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Neurological
Burning
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Twitching of Face
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Dizziness
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Multiple Sclerosis
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Shingles / Herpes
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Carpal Tunnel
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Vertebral and Spinal Cord Injury
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Dural Ectasia
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Numbness
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Sleeping Disorders
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Stabbing
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Cerebral Palsy
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Epilepsy
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Parkinsons
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Stroke
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Cerebral Vascular Accident (Stroke)
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Fatigue
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Peripheral Neuropathy
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Syringomyelia
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Cerebral-vascular Accident
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Fibromyalgia
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Post Polio Syndrome
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Tethered Cord
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Cerebrospinal Fluid Leak
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Herniated Disc
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Sciatic Pain
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Bell's Palsy
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Brain Disorder
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Tingling
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Chiari Malformation
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Huntington Disease
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Seizure Disorder
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Brain Injury
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Transient Ischemic Attacks (TIA)
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Chronic Pain Disorder
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Loss of Sensation
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Shingles
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Other Neurological
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Musculoskeletal
Muscular Dystrophy
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Adhesive Capsulitis
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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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Myasthenia Gravis
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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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Fracture
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Osgood-Schlatter Disease
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Ankylosing Spondylitis
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Scleroderma
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Chronic Fatigue Syndrome
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Torticollis
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Gout
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Osteoarthritis
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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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Hereditary/Congenital Deformity
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Osteomalacia
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Artificial Joints / Special Equipment
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Sinus Problems
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Compartment Syndrome
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Jaw Pain (TMJD)
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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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Joint Injury
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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 Stiffness / Swelling
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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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Other Musculoskeletal
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Blood
Haemophilia
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Thrombosis/Embolism
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Hepatitis
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High Cholesterol
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HIV
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Anemia
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HIV/AIDS
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Bleeding Disorder
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Hypercoagulability
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Blood Thinner Medication
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Polycythemia
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Fainting Spells
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Stroke
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Other Blood
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Immune
Cancer
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Rheumatoid Arthritis
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CVID
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Sjogren's Syndrome
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HIV/Aids
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Hodgkin Lymphoma
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Infectious Mononucleosis
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Leukemia
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Allergies
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Lupus
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Anaphylaxis
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Non-Hodgkin Lymphoma
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Other Immune
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Family History
Arthritis
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Cancer
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Cardiovascular
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Diabetes
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Respiratory
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Endocrine
Blood Sugar Managed?
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Diabetes
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Wound Healing Status?
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General Injury Related Questions
What is the next competition/challenge?
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Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Miscellaneous
Dentures
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Hearing Impaired
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Insomnia
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ADHD
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Autism
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Contact Lens
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Dental Bridge
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Dental Implants
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Prenatal (check boxes to enter details below)
Due Date
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Trimester
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Weeks Pregnant
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Number of previous pregnancies/births?
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Anemia
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Leaking Amniotic Fluid
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Bladder Infection
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Blood Clot (Phlebitis)
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Miscarriage
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Nausea
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Problems with Placenta
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Preterm Labour
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Pre-eclampsia (toxemia)
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Sciatica
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Separation of Rectus Muscle (diastasis recti)
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Separation of Symphysis Pubis
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Twins or More
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Visual Disturbances
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Previous C-Section
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Heart Attack
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Stroke
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Carpal Tunnel Syndrome
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Allergy to Nut Oils
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Hypoglycemia
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High Risk Pregnancy
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Birth Location
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Doula
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Placental Location
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Baby's Sex
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Sacral Injury
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Tailbone Injury
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Massage Goals
Alternative Therapy
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Stress Relief
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Balance
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Flexibility
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Improve Fitness
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Increase Well-Being
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Injury Rehabilitation
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Positive Reinforcement
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Address Health Issues
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Strength Training
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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
Environmental
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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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Emotion / Mood
PTSD
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Despair
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Rate the stress in your life (1-10)
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Fear
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Sadness
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Grief
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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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