Personal Information. Client Questionnaire. Basic Information. Date of Birth. Male Female Other Not Specified. Contact Information
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- Oswin Ross
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1 Client Questionnaire Personal Information Basic Information First Name Last Name Date of Birth Male Female Other Not Specified Contact Information Preferred Phone Cell Address City State Zip Emergency Contact Information Contact Name Phone Relationship Doctor Information Physician Name Phone
2 Complaint Information Cause of Injury or Concern How long since first noticed Primary Complaint Past Treatment
3 Respiratory Asthma Shortness of Breath Bronchitis Chronic cough Emphysema Cardiovascular Blood Clots Cardiovascular Accident Cerebral-vascular Accident Cold Feet Cold Hands Congestive Heart Failure Heart Attack Heart Disease High Blood Pressure Low Blood Pressure Lymphedema Myocardial Infarction Pacemaker Phlebitis Stroke Thrombosis/Embolism Varicose Veins Skin Bruise Easily Skin Irritations Hypersensitive Reaction Melanoma Skin Conditions Head & Neck Ear Problems Headaches Hearing Loss Jaw Pain (TMJD) Migraines Sinus Problems Vision Loss Vision Problems Infectious Conditions Athlete's Foot Respiratory Conditions Hepatitis Skin Conditions Herpes HIV Women Gynecological Conditions Pregnancy Soft Tissue / Joint Dysfunction Ankles (Left) Ankles (Right) Arms(Left) Arms(Right) Feet (Left) Feet (Right) Hands (Left) Hands (Right) Hips (Left) Hips (Right) Knees (Left) Knees (Right) Legs (Left) Legs (Right) Lower Back (Left) Lower Back (Right) Mid Back (Left) Mid Back (Right) Neck (Left) Neck (Right) Shoulders (Left) Shoulders (Right) Upper Back (Left) Upper Back (Right) Family History Cardiovascular Conditions Respiratory Conditions
4 Miscellaneous Allergies Cancer Dizziness Hemophilia Mental Illness Other Medical Conditions Surgical Pins or Wire Anaphalaxis Crohn's Disease Epilepsy Insomnia Osteo Arthritis Rheumatoid Arthritis Artificial Joints / Special Equipment Diabetes Fibromyalgia Loss of Sensation Osteoporosis Shingles Arthritis Digestive Conditions Gout Lupus Other Diagnosed Disease Stress Neurological Burning Cerebral Palsy Herniated Disc Multiple Sclerosis Numbness Parkinsons Stabbing Tingling Medications Please list any medications or drugs you are currently on
5 Client Waiver form The following statements are required under Title 25, Texas Administrative Code, Chapter 140, Health Professions Regulation, Subchapter H, Massage Therapists. I understand that I am participating in a student internship program and, by doing so, I am helping these students complete their massage therapy program of studies. I understand that massage therapy is regulated as a healthcare profession; that massage therapists are required to do an initial consultation with each client prior to the first massage therapy session; that I must update any changes in my information on follow-up sessions; and that my signature is required below. I understand that Swedish Massage is the massage/bodywork technique primarily used during these sessions and is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. I understand that if I experience pain or discomfort during the session, I will immediately inform my student therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my student therapist responsible for any pain or discomfort I experience during or after the session. I understand that I will be appropriately draped throughout the session and that my modesty will be respected at all times, and that breast massage will not be performed. I understand that I must inform my student therapist of any areas I wish avoided. I understand that the services offered today are not a substitute for medical care. I understand that my student therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. I affirm that I have notified my student therapist of all known medical conditions and injuries. I agree to inform the student therapist of any changes in my health and medical condition. I understand that there shall be no liability on the student therapist s part should I forget to do so. I understand that massage is entirely therapeutic and non-sexual in nature. I understand that if I become uncomfortable for any reason, I may ask the student therapist to cease the massage and the student will end the session. Either party has the right to terminate the session for inappropriate behavior. I affirm that I am not contagious at the time of this appointment. By signing this release, I hereby waive and release my student therapist from any and all liability, past, present, and future relating to massage therapy and bodywork. Please print this form and bring it with you to your appointment. Please arrive ten minutes prior tp your appointment time. I have read the statement above and agree to all the policies there in Client Signature* Date*
intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:
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1 Patient Information : Name: Last First MI Email address: Mailing Address: Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Can we leave messages on voice mail at home/work/cell? Yes
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3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
HEALTH HISTORY FORM. Doctor s Name: Telephone #: Permission to consult with your Doctor: Yes No Initials:
HEALTH HISTORY FORM How did you hear about our clinic? Yellow Pages Website Our sign Facebook Other? Family/Friend/Co-Worker WHO? Permission to acknowledge the person who referred you (Initials) Name:
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.