Matthew Howe of Touch Education, LLC Confidential Intake Form

Matthew Howe of Touch Education, LLC Confidential Intake Form
This form must be completely filled out, signed, dated and returned
I) Client Name:
Date of Birth:

Month Day Year
Date
Street Address:
Gender
City:
State:
Zip:
Phones: Home:
Work:
Cell:
Current Employer:
Occupation:
Emergency Contact:
Phone:
A. List ALL surgeries, injuries, illnesses and accidents with dates, to include all motor vehicle accidents, worker’s compensation injuries and falls. (if none, write “none”)
B. List ALL medications, supplements or herbal remedies you are currently taking: (If none, write “none”)
C. Check all current conditions, which apply to you. Check “No” for others:
Pregnancy

Yes No
Hypertension

Yes No
Diabetes

Yes - Type 1 No - Type 1 Yes - Type 2 No - Type 2
Varicose Veins

Yes No
Stroke (CVA, TIA)

Yes No
Headaches

Yes No
Disc Problems

Yes No
Blood Clots

Yes No
Bruise Easily

Yes No
Osteoporosis/Osteopenia

Yes No
Cardiac Conditions

Yes No
Cardiac Conditions: If YES please specify
Cancer: If, YES please specify
Allergies: if YES please specify:
Arthritis: Please specify location
Do you have experience with manual therapies?

Massage Therapy Craniosacral Therapy Acupuncture Chiropractic Energetic Therapy
Are you presently under the care of a physician?
Physician's phone:
What is the diagnosis?
Date of diagnosis:

Month Day Year
Date
Are you experiencing discomfort, pain, numbness, tingling, or limited movement? If yes, when did the discomfort begin and where?
What activity were you doing when it started? Do you feel pain with movement? Do you feel pain with touch? Please describe your pain/discomfort/sensation:
COVID-19 Related Questions
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Yes No
Have you had a fever in the last 24 hours of 100°F or above?

Yes No
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?

Yes No
Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?

Yes No
Do you have special needs I should prepare for:
Do you have any questions or concerns:
If you answer YES to any of these questions, please contact me and I will happily reschedule you.

Office Kindness Policy (Version 1.0)
- I will wait in my car to receive a text message that it is safe to come into the building and treatment room.
- I will wear a mask into the office and treatment room. Should I forget my mask, I will text Matt to let him know.
- I will wear a mask as I leav e the office from the treatment room.
- I will wear a mask in the common areas of the office.
- I will wash my hands after using the restroom.
This is an expression of kindness and respect. To assure the safety of those Matthew share’s the room and office with.
I have read and agree to abide by the office kindness policy. (initial here)
I understand that Matthew Howe of Touch Education, LLC will provide a licensed massage and/or bodywork session. The therapy provided will fall under the scope of a Licensed Professional Health Care Practitioner. I release the practitioner from all liability due to injury or other causes resulting from the treatment. I expressly give permission for the session(s) I receive, and I understand that these services are not a substitute for medical care. I have stated all medical conditions of which I am aware, and I will notify Matthew Howe of Touch Education, LLC of any changes in my health status.

I understand that I am responsible for all fees associated with this service and agree to pay at the time of service rendered.
Patient's Signature:

Clear
Date:

Month Day Year
Date
407.308.2110 Matthew Howe, BCMTB, LMT, ICST
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Matthew Howe of Touch Education, LLC Confidential Intake Form

COVID-19 Related Questions