intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:
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1 intake form Page 1`of 5 About You : Name: Sex: Male Female Address: City: State/Province: Country: Zip/Postal Code: Home Phone Number: Mobile Phone Number: Address: Birthday: Marital Status: Married Single Occupation: Employer or School: General Health Information: Family Doctor s Name: Family Doctor s Address: Family Doctor s Phone: Family Doctor s Address:
2 Are you currently seeing other health care professionals? (check all that apply) Chiropractor Physiotherapist Acupuncturist Massage Therapist Page 2`of 5 How would you rate your general health? Excellent Good Fair Poor Please list any current medications and the conditions they are treating: Please list any major injuries, accidents or surgeries (including the approx. date): Do you have any previous experience with Massage Therapy? Yes, my last massage therapy treatment was on Date No Reason for visit: Primary complaint, cause and location of discomfort: When did the pain/discomfort start? How often do you feel pain/discomfort Constantly Comes and goes suddenly Comes and goes gradually How does the pain/discomfort feel: Sharp Aching Throbbing Burning Tight
3 Page 3`of 5 Pain/discomfort is brought on/made worse by: Sitting Standing Lifting Bending Exercise/Physical Activity Pain intensity: Mild Moderate Severe Pain/discomfort feels better with: Ice Heat Anti-inflammatory medication Rest Activity Health History: Head/Neck: Whiplash Headaches/Migraines Concussion Ringing in Ears Hearing Loss Vision Problems Brain Injury Sinus Pain Respiratory: Asthma Shortness of Breath Chronic Cough Bronchitis Emphysema Sinusitis Frequent Colds Pneumonia Tuberculosis Smoker Cardiovascular: High Blood Pressure Low Blood Pressure Heart Attack Angina / Chest Pain Stroke Chronic Congestive Heart Failure Heart Disease Poor Circulation Phlebitis / Varicose Veins Pacemaker Hemophilia Family History of Cardiovascular Problems Digestive: Constipation Diarrhea Crohn s / Colitis Nausea Diverticulitis Ulcers
4 Page 4`of 5 Nervous System: Sensory Loss / Change Numbness / Tingling Spinal Cord Injury Thoracic Outlet Syndrome Carpal Tunnel Syndrome Sciatic Epilepsy Seizures Cerebral Palsy Parkinson s Multiple Sclerosis Musculoskeletal System: ` Sprain / Strain Dislocation Arthritis Family History of Arthritis Tendonitis Bursitis Fractures Plantar Fasciitis Postural Deviation Degenerative Disc Disease Pins / Plates / Wires / Artificial Joint Conditions: Cancer Diabetes Fibromyalgia Chronic Fatigue Syndrome Psychiatric Disorder Skin/Infections: Infectious Skin Conditions Bruise Easily Hives Allergies / Hypersensitivity Dermatitis / Eczema Open Wound / Lesion Burns Acne Hepatitis HIV / AIDS Muscle/Joint Pain: Jaw Neck Upper Back Middle Back Lower Back Shoulder Arm Elbow Wrist Hand Hip Leg Knee Ankle Feet For Women: Pregnant # of Children Gynecological Problems
5 Page 5`of 5 General: We like to recognize those people/organizations that refer patients to us. Please let us know how you found us: Doctor Name: Friend Name: Clinic website / Google Facebook / Twitter Advertisement Yellow Pages I hereby state that, to the best of my knowledge, my answers to the above questions are correct. I agree to and consent to assessment and treatment. I understand and consent that my medical information may be shared by the various care providers involved in my treatment. Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage. X signature date
Personal Information. Client Questionnaire. Basic Information. Date of Birth. Male Female Other Not Specified. Contact Information
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FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET ADDRESS: PROVINCE: HOME PHONE: (CHECK WHICH PREFERRED) WORK PHONE: EMAIL ADDRESS: NEW LEGISLATION REQUIRES THAT WE OBTAIN CONSENT PRIOR TO SENDING EMAILS TO
More informationREFLEXOLOGY HEALTH RECORD
REFLEXOLOGY HEALTH RECORD THIS FORM IS TO BE COMPLETED BY THE CLIENT FIRST THEN BY PRACTITIONER FOR INITIAL SESSION Client Date of Birth Telephone Home Business Ext Email Address Street # City Street Name
More informationWelcome to our office!
Welcome to our office! Today s Date / / Patient Title: Mr. Mrs. Ms. Miss Dr. Name: Preferred Name: Address: City: State: Zip Code: Home Phone: Work Phone: Mobile Phone: Email Address: Preferred Contact
More informationDear Yoga Therapy Case Study Applicant,
Dear Yoga Therapy Case Study Applicant, Many thanks for your interest in our program. We will do our best to secure a spot for you in our on- going free Saturday Clinic. Our only request is your commitment
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