MASSAGE I TAKE FORM RAQUEL CARTER LICE SED MASSAGE THERAPIST EXERCISE PHYSIOLOGIST REFLEXOLOGIST
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1 MASSAGE I TAKE FORM RAQUEL CARTER LICE SED MASSAGE THERAPIST EXERCISE PHYSIOLOGIST REFLEXOLOGIST CLIE T I FORMATIO NAME: DATE: Last First Middle Initial BIRTHDAY: MARITAL STATUS: S M W D DP ADDRESS: Street and /or Apartment # City State Zip Code HOME PHONE: CELL PHONE: EMPLOYER: WORK PHONE: MASSAGE HISTORY How often have you received a massage in the past? Never Time(s)a week Time(s) a month Times a year When was your last massage? *What did you like most about your previous massage? Why? *What did you least like about your previous massage? Why? *Are you sensitive to (circle all that apply) oils lotions scents (If so please explain) * IF APPLICABLE
2 MEDICAL HISTORY Tell Me What s Bothering You Today: How long has this bothered you? Week(s) Month(s) Year(s) (Not Sure) What activities aggravate/elevate this condition? What activities improve/relieve this condition? Are you under any medical/therapeutic treatment? Yes No If Yes, Explain: Do you have any artificial joints, plates, screws, etc.? Have you had any recent surgeries? Have you had any recent injuries? Have you been in a car accident in the last two years? Yes No Yes No Yes No Yes No Mark an X on the diagram to the right to indicate your Area s of pain. Mark an X to represent your level in each Health Low High Energy Low High Stress Low High
3 MASSAGE THERAPY INFORMED CONSENT I, (client) understand that massage therapy provided by, Raquel N. Carter C.M.T. (massage therapist) is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch. Any other intended purposes for massage therapy are specified below: NONE The general benefits of massage, possible massage contraindications and the treatment procedure have been explained to me. I understand that massage therapy is not a substitute for medical treatment or medications and that it is recommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medication, and that spinal manipulations are not part of massage therapy. I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes. I have received a copy of the therapist s policies; I understand them and agree to abide by them. Client Signature: Date: *Please do not sign this form if you have NOT read and understand the office policies. By signing this form, you will be responsible for possible fees or other charges applicable.
4 Health History Musculo-Skeletal Skin Reproductive System *Headaches *Rashes *Pregnancy *Joint stiffness/swelling *Allergies *Current *Previous *Spasms/cramps *Athlete s Foot *PMS *Broken/fractured bones *Warts *Menopause *Strains/sprains *Moles *Pelvic Inflammatory Disease *Back, hip pain *Acne *Endometriosis *Shoulder, neck, arm, hand pain *Cosmetic Surgery *Hysterectomy *Leg, foot pain *Other: *Fertility concerns *Chest, ribs, abdominal pain *Prostrate problems *Problems walking Digestive *Jaw pain/tmj *Nervous stomach Other: *Tendonitis *Indigestion *Loss of appetite *Bursitis *Constipation *Forgetfulness *Arthritis *Intestinal gas/bloating *Confusion *Osteoporosis *Diarrhea *Depression *Scoliosis *Diverticulitis *Difficulty concentrating *Bone or joint disease *Irritable bowel syndrome *Drug use *Other: *Crohn s Disease *Alcohol use *Colitis *Nicotine use *Other: *Adaptive aids Circulatory & Respiratory *Caffeine use *Dizziness *Hearing impaired *Shortness of breath *Visually impaired *Fainting ervous System *Burning upon urination *Cold feet or hands *Numbness/tingling *Bladder infection *Cold sweats *Twitching of face *Eating disorder *Swollen ankles *Fatigue *Diabetes *Pressure sores *Chronic pain *Fibromyalgia *Varicose veins *Sleep disorders *Post/Polio Syndrome *Blood clots *Ulcers *Cancer *Stroke *Paralysis *Infectious disease (please list) *Heart condition *Herpes/shingles *Allergies *Cerebral Palsy *Other congenital or acquired *Sinus problems *Epilepsy disabilities (please list) *Asthma *Chronic Fatigue Syndrome *High blood pressure *Tremors *Surgeries *Low blood pressure *Multiple Sclerosis *Other: *Lymphedema *Muscular Dystrophy *Other: *Parkinson s disease For clients who need mobility *Spinal cord injury assistance, please give your *Other: height: weight Please list any additional comments regarding your health & well-being:
5 Policies and Procedures The following policies are to help everyone get the best treatment possible. Please read them carefully and ask if you have any questions. 1. There is a 24 hour cancellation policy. As standard policy in the industry, and courtesy to your therapist(s), if you are unable to make your scheduled appointment, please call at least 24 hours prior to your appointment to cancel or re-schedule. This will help insure that spot will be available for those who may other wise be in need of your time slot. If you fail to allow for a 24 hour notice, a $30.00 fee will be assessed to your account and will be expected at time of next service. 2. Please arrive on time. This is very important because the therapist(s) wants to be able to give you your full session time, as well as, there may be another appointment following your session. To help keep all massages starting on time, please arrive on time, or 5 minutes early to allow for extra time if needed (restroom, weather conditions, etc.) If you are late and there is another appointment following yours, know that the therapist(s) may not be able to give you our full schedule time. If you receive a shorter massage than scheduled due to a late arrival, please understand you will be expected to pay for a full session. 3. Payment due at time of service. Payment for a massage will be expected at the time of service. Please be prepared to do so. Your therapist has the right to charge a late fee of $5.00 to any payment not received on the day of service. If you are unable to pay for our service please inform your therapist so that a payment arrangement can be made and you can avoid a late fee. 4. Right to refuse service. The therapist(s) have full rights to refuse service to any person(s), even if you have received a treatment in the past. Please understand that massage therapy is a healing therapy and if the therapist(s) should feel that they are unable to treat a person to the best of their ability, or should feel uncomfortable treating a person for ANY reason, they can refuse any or all treatment(s). 5. There are O exceptions to these policies. If you feel you should be exempt from one or more of these policies than please inform your therapist before signing the consent form. Your signature confirms your understanding, and your willingness to follow these policies and pay any fees applicable. Please note that the therapist(s) here are independent and are not paid an hourly wage. Activa is not responsible for covering payments due to the therapist by the clients. To help ensure our therapist s time is valued, please follow the listed policies. Your cooperation is greatly appreciated. ***PLEASE KEEP THIS COPY FOR YOUR RECORDS.
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Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation
Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
COMPREHENSIVE HEALTH & WELLNESS PROFILE
Patient Name DOB COMPREHENSIVE HEALTH & WELLNESS PROFILE The human body is designed to be healthy. Throughout life, events occur which damage your natural health expression. As a full spectrum Chiropractic
Acupuncture & Herbal Therapies
Acupuncture & Herbal Therapies 2520 Central Ave. St. Petersburg, FL 33712 (Phone) 727-551-0857 (fax) 727-202-6896 Last Name: First Name: Male/Female: Date of Birth: Address: City: State: Zip: Home Phone#:
What do you believe is causing your most important health concern?
Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: _ First Name: Sex: M / F Address: City Postal Code: Home Phone: Work Phone: Cell Phone: Cell Phone Provider: E-mail: Occupation: Marital Status: No. of children:
MEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.
If you have any questions, feel free to contact us at 475- WLNS (9567) or
UC Health Integrative Medicine UC Health Physician s Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH 45213 UC Health Physician s Office South 7675 Wellness Way, 4 th Floor West Chester, OH
PATIENT INTAKE FORM Health & Wellness
PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address
Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP
Shiatsu Intake Form DATE PURCHASED PRODUCT/SERVICE FIRST NAME LAST NAME Date of Birth Age Height Weight Home Address City State ZIP Home Phone Cell Phone Email Name of Emergency Contact Would you like
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
Thank you for choosing Therapy Works to assist you with your current condition.
Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important