Forge Body Therapy Patient Intake

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number*
Format: (000) 000-0000.
This is my:*
E-mail*
Emergency Contact*
Phone Number*
Format: (000) 000-0000.
Occupation
Medications
Allergies
History of Pathology
1. List Areas of Discomfort or Pain*
2. Describe Onset of Discomfort or Pain*
3. Rate of Pain Today*
ConstantOff/OnAt RestWith ActivityOther
MorningAfternoonEveningDuring SleepOther
6. Have you ever injured this area before?*
7. Have you ever been in an accident (automobile, work, falls, etc.) ?*
8. List all related treatments received for this injury.
9. Have you ever received therapeutic massage for a specific problem or injury?
Was the treatment used effective?
10. Is there anything that you do that creates, increases or decreases pain? *
11. What are the physical duties required of your occupation?*
12. What activities/hobbies do you enjoy?*
13. Please list exercise and stress reduction activities (including frequency).*
BackSideStomachOther
15. Are you currently seeing any other healthcare professional?
Please check any symptoms that apply to you and indicate right or left when applicable:
TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther
Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
Session Policies:

Patient services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off your cell phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged for your session

       • Should the session require, after your therapist has left the room, you may disrobe to your comfort level

       • If needed, you will be draped appropriately with a towel, however you may request a full sheet at any time

       • You will have a consultation with your therapist to discuss your session

       • I understand that my therapist or I may end the session at any time for any reason

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Patient Agreement:

I understand that Forge Body Therapy does not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or provide chiropractic adjustments.

I acknowledge that a Forge Session is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to participate in Forge Sessions as a form of therapeutic treamtent.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my mobility and movement therapist so they can make adjustments to the treatment.

COVID19 - I have educated myself to the best of my abilities about the COVID19 Virus and the risks involved with regard to infection, spread and complications due to the contraction of this disease. Complications that include but are not limited to: respiratory dissress and abnormal blood clotting which may/or may not present but could still negatively impact the body due to the Forge Body Therapy treatment.

I have stated my pertinent medical conditions, and will update the therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Forge Body Therapy and my mobility and movement therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty: