Intake Form

Full Name

Email Address

Sex Female Male

Birthdate

Home Address

Occupation:

Primary Physician: (optional)

Emergency Contact:

Emergency Contact Relationship:

Emergency Contact Phone:

How did you hear about us?

Are you taking any medications? Yes No

If Yes, please indicate below:

Any surgeries in the past year?

Have you had any orthopedic injuries? Yes No

Are you currently pregnant? Yes No

If yes, how far along:

Do you suffer from chronic pain? Yes No

Any high risk factors?

Body Issues to Address
Head
Neck
Upper Back
Lower Back
Shoulder
Left/Right Arm
Hips
Left/Right Thigh
Legs
Foot

Describe Sensation(s)

Cause of injury or concern

How long since first noticed

Do you have any existing conditions?
Asthma
Shortness of Breath
Bronchitis
Chronic Cough
Emphysema
Blood Clots
High Blood Pressure
Varicose Veins
Congestive Heart Failure
Phlebitis
Heart Attack
Lymphedema
Heart Disease
Myocardial Infarction
Cold Hands
Pacemaker
Cardiovascular Accident
Low Blood Pressure
Cerebral-vascular Accident
Stroke
Cold Feet
Thrombosis/Embolism
Bruise Easily
Hypersensitive Reaction on Skin
Skin Conditions
Skin Irritations
Melanoma
Ear Problems
Headaches
Hearing Loss
Jaw Pain (TMJD)
Migraines
Sinus Problems
Vision Loss
Vision Problems
Athlete's Foot
Hepatitus
Herpes
Respiratory Conditions
HIV
Gynecological Issues
Pregnancy
Cardiovascular Conditions
Respiratory Conditions
Burning
Tingling
Cerebral Palsy
Multiple Sclerosis
Numbness
Stabbing Pain
Parkinsons
Herniated Disc
Allergies
Dizziness
Mental Illness
Anaphylaxis
Epilepsy
Osteoarthritis
Artificial Joints/Special Equipment
Fibromyalgia
Osteoporosis
Arthritis
Gout
Cancer
Hemophilia
Surgical Pins or Wire
Crohn's Disease
Insomnia
Rheumatoid Arthritis
Diabetes
Loss of Sensation
Shingles
Digestive Conditions
Lupus
Other Diagnosed Diseases
Other Medical Conditions

Are there any other conditions that is not listed above? If yes, please specify:

COVID-19 SYMPTOMS

Please check the box below if any of the following are true:

• Have had a fever within the last 24 hours
• Recently experienced respiratory/flu symptoms, sore throat, or shortness of breath
• Contact, within the last 14 days, with anyone diagnosed with COVID or related symptoms

COVID Symptoms Questionnaire I have no symptoms

Have you had a professional massage before? Yes No

What pressure do you prefer? Light - Medium Medium - Medium Deep
Deep

Do you prefer a quiet massage or do you enjoy conversation?

Do you want the table warmer on or off during your massage?

What are your goals for this treatment session?

Is there any past treatments done? If yes, please specify