CompassionMassage.com. Client Intake Form
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1 Name: Phone: ( CompassionMassage.com Client Intake Form ) Address: _ City: State: Zip: Date of Birth: Occupation: Referred by: In case of emergency: Phone: ( Chiropractor: ) General & Medical Information: If you answer "yes" to any of the following questions, please explain as clearly as possible. Yes No Have you ever had professional massage? Yes No Do you sit for long periods of time such as at a desk or in a car driving? If yes, please explain in the comments section. Yes No Are you wearing contact lenses? Yes No Have you ever had surgery? If yes, please explain in the comments section. Yes No Are you allergic to any oils, lotions, or ointments? If so Yes No Do you have any other medical conditions that I should be please name: aware of? Yes No Are you very sensitive to touch / pressure in any area? Sleep position(s): Car Accidents: Comments: Rate your pain on the scale No Pain Moderate Worst Pain Define the quality of your pain: (achy, throbbing, tender, radiating, stabbing, tingling, numbness, spasms) Please circle specific areas you would like the therapist to concentrate on during your session
2 Helpful Suggestions to Enhance Your Session: Please remove all loose articles of clothing and jewelry Your therapist will drape your body appropriately with a sheet and blanket and ensure the room temperature matches your preferred preference. We encourage you to give your therapist feedback with regards to the pressure applied to your body during your massage. We strongly encourage you to point out any pain points or ticklish areas on your body. At any time during your consultation or during your massage, please feel open to ask questions, this session is about you, your body and your health. Please Read the Following Disclaimers and Sign: It is important to know massage may not be appropriate with certain medical conditions or for injuries to specific body parts. If during the session you feel any pain or discomfort, it is highly recommended that you notify your therapist so that treatment pressure can be adjusted immediately. Massage is not a substitute for medical examination, diagnosis, or treatment. It is recommended that you seek the attention of a qualified medical professional for any mental or physical conditions that require such attention. Massage therapy is not a substitute for care such as spinal or skeletal adjustments, therefore, if you require such treatment it is recommended you consult with a qualified medical professional such as a chiropractor. It is important that you keep your therapist current on any changes in your medical conditions as massage is not appropriate under certain circumstances. By signing this form and going through our intake process, you affirm that you have answered all questions honestly and that there is no liability on the therapist in the case you do not disclose any conditions or update him or her with regards to changes in your medical condition that might impact your reason to receive massage. Compassion Massage Therapeutic Massage Clinic LLC and its therapists are professional complementary healthcare providers, any comments, suggestions, or solicitation of sexual behavior is grounds for immediate termination of your session without refund. Client Signature: Date: Therapist Signature: Date:
3 Health History Check the following conditions that apply to you, past and present. Please add your comments to clarify the condition. Musculo-Skeletal o Headaches o Joint stiffness/swelling o Spasms/cramps o Broken/fractured bones o Strains/sprains o Back, hip pain o Shoulder, neck, arm, hand pain o Leg, foot pain o Chest, ribs, abdominal pain o Problems walking o Jaw pain/tmj o Tendinitis o Bursitis o Arthritis o Osteoporosis o Scoliosis o Bone or joint disease Circulatory and Respiratory o Dizziness o Shortness of breath o Fainting o Cold feet or hands o Cold sweats o Swollen ankles o Pressure sores o Varicose veins o Blood clots o Stroke o Heart condition o Allergies o Sinus problems o Asthma o High blood pressure o Low blood pressure o Lymphedema Skin o Rashes o Allergies o Athlete s Foot o Warts o Moles o Acne o Psoriasis o Cosmetic surgery Digestive o Nervous stomach o Indigestion o Constipation o Intestinal gas/bloating o Diarrhea o Diverticulitis o Irritable bowel syndrome o Crohn s Disease o Colitis o Adaptive aids Nervous System o Numbness/tingling o Twitching of face o Fatigue o Chronic pain o Sleep disorders o Ulcers o Paralysis o Herpes/shingles o Cerebral Palsy o Epilepsy o Chronic Fatigue Syndrome o Multiple Sclerosis o Muscular Dystrophy o Parkinson s disease o Spinal cord injury Reproductive System o Pregnancy: o Current o Previous o PMS o Menopause o Pelvic Inflammatory Disease o Endometriosis o Hysterectomy o Fertility concerns o Prostate problems Other o Loss of appetite o Forgetfulness o Confusion o Depression o Difficulty concentrating o Drug use o Alcohol use o Nicotine use o Caffeine use o Hearing impaired o Visually impaired o Burning upon urination o Bladder infection o Eating disorder o Diabetes o Fibromyalgia o Post/Polio Syndrome o Cancer o Infectious disease (please list) o Other congenital or acquired disabilities (please list) o Surgeries Please list any additional comments regarding your health and well-being: I have stated all conditions that I am aware of and this information is true and accurate. I will inform the health care provider of any changes in my status. Client s Signature: Date:
4 Prescription Medications
5 OFFICE POLICIES 1. Cancellation and No-Show Policy We strive to meet our client s needs for massage by effectively managing our schedule. 24 hour advance notice is required when canceling an appointment, except in cases of illness, emergency or inclement weather. Cancellations without 24 hour notice will result in a $35 charge for your session, as that time has been set aside specifically for you. The cancellation fee must be paid on the day you notify our office of your need to cancel and must be paid prior to scheduling/receiving your next appointment. In the event that you fail to show up to your appointment entirely, resulting in a complete loss of time to your therapist, you will be required to pay the full amount for the scheduled session on the day of your missed appointment. 2. Lateness Policy Our clinic schedules 30 minutes between appointments to accommodate for the time we spend before and after each massage with our clients. Time for your appointment has been arranged especially for you. Please arrive minutes early for your appointment as your massage is scheduled to begin at the appointment start time. If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours and full payment will be expected. 3. Permission to Contact You Your feedback is important to us as it helps us understand your specific needs and how we can better serve you. We are committed to delivering the highest level of care for you which is why we would like your feedback after your initial massage appointment. You will receive an requesting your review of our clinic to complete at your convenience. This feedback provides us the opportunity to learn more about your overall experience so that we can measure the effectiveness of our therapeutic massage and make modifications, if necessary. In addition, we provide our clients with a monthly newsletter on health tips, reviews of peer providers, and news about the clinic. Please advise us on how you prefer to be contacted by our clinic. Preferred Preferred Contact # Printed Name Signature & Date
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intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:
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Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
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New Patient Information
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CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
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PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
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Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
Today s : MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: I am a Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code: Home #: Work #: Cell
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
Sydney Chiropractic, DR. DAVID DUNN
PERSONAL HISTORY Name: Address: City: Province: Postal Code: Home Phone: Birthdate: Age: Sex: M F # of Children Business/Employer: Business Phone: Type of Work You Do: E-mail: Emergency Contact: Phone
Application for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to
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
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
New Practice Member Paperwork
Cornerstone Family Chiropractic Health Information Form 928.237.9477 www.cfc4familyhealth.com 2225 E State Route 69 Suite A Prescott, AZ 86301 New Practice Member Paperwork This form is for adults only.
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
Practice Member Profile
Practice Member Profile Please print Name: : Phone number: (H) (C) Cell provider: Address: City: State: Zip: of Birth: Age: Male Female (circle one) Marital Status: Name of Spouse: Number of Children:
Vibrant Life Healthcare 6105 Patricia Bay Highway Victoria, BC, V8Y 1T4
Vibrant Life Healthcare 6105 Patricia Bay Highway Victoria, BC, V8Y 1T4 Patient Name (As it appears on your carecard) LAST FIRST MIDDLE What name would you prefer us to use? Address: City: Postal Code: