printed-intake-form

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First Name
Date of birth

Month Day Year
Date
Last Name
Referred by
Email Address
example@example.com
Mobile Phone #
Home Phone #
Work Phone #
Address

Street Address

Street Address Line 2

City State

Zip Code
Emergency contact name
Physician's name
Emergency contact relationship
Physician's phone #
Emergency phone #
Date of initial visit

Month Day Year
Date
How would you rate your general health?
Have you had a professional massage before?

Yes (Date of last treatment ) No
List current medications & the conditions they are treating
List any major accidents or surgeries (including dates)

Month Day Year
Date
Please tell us about any allergies or hypersensitivities
Reason for initial visit
| INTAKE FORM Tired of organizing paper? Try online intake forms at ClinicSense.com
CARDIOVASCULAR
RESPIRATORY

Asthma Shortness of breath Chronic cough Bronchitis Emphysema Sinusitis Frequent colds Smoker Family history of respiratory difficulties
Emphysema

Headaches / migraines Vertigo / dizziness High blood pressure Low blood pressure Ringing in ears Hearing loss Heart attack Stroke Vision problems Vision loss Heart disease Poor circulation Phlebitis / varicose veins Pacemaker Hemophilia Chronic congestive heart failure Family history of cardiovascular problems
SKIN & INFECTIONS

Hepatitis HIV / AIDS Herpes Tuberculosis Lyme disease Infectious skin conditions
NERVOUS SYSTEM

Sensory loss / change Numbness / tingling Sciatica Epilepsy Seizures Multiple sclerosis
OTHER CONDITIONS
MUSCULOSKELETAL SYSTEM

Cancer Diabetes Unexplained weight loss Digestive conditions Arthritis Family history of arthritis Fibromyalgia Chronic fatigue syndrome Osteoporosis Tendonitis Depression Anxiety Bursitis Jaw pain (TMJ) Psychiatric disorder Pins / plates / wires / artificial joint Other conditions
REPRODUCTIVE

Pregnant Given birth Gynecological problems
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and 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.
Signature:

Clear
Date:

Month Day Year
Date
Should be Empty:

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CARDIOVASCULAR

OTHER CONDITIONS