Structural Medicine Client 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
Birth Date

MonthDayYear
Phone Number*
E-mail*
Emergency Contact*
Phone Number*
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*
4. List all related treatments received for this (or other) injury(ies). Were those treatments effective?
5. Frequency - please select the most accurate*

ConstantOff/OnAt RestWith ActivityOther
6. At what time of day is the pain at its worse?*

MorningAfternoonEveningDuring SleepOther
7. Have you ever broken any bones or had any other surgeries? Please list with years of incidents/procedures*
6. Have you ever been in an accident (automobile, work, falls, etc.) ?*
7. Have you ever received treatment from other Structural Integrators or Massage Therapists?
8. What are the physical duties required of your occupation or other responsibilities?*
9. Is there anything that you do that creates, increases or decreases pain? *
10. What activities/hobbies do you enjoy?*
11. Please list exercise and stress reduction activities (including frequency).*
12. In what position do you most often wake up?*

BackSideStomachOther
13. Are you currently seeing any other healthcare professional?
Please check any symptoms that apply to you and indicate right or left when applicable:
Head

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
Neck

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
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Arms & Hands

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

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

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
Hip

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
Legs and Feet

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
Massage Policies: Client 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 20 minutes late

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

• You will be asked to stand and receive Myo-Fascial Length Testing (MFLT) while in undergarments. Please where whatever you are most comfortable in.

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

• I understand that my Structural Medicine Specialist or I may end the session at any time for any reason

• Inappropriate behavior will not be tolerated and will permit my Specialist to end the session at any ppoint, and be paid in full for the schedule appointment in this circumstance.

Client Agreement: I understand that Structural Medicine Specialists and Licensed Massage Therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization. I acknowledge that Structural Medicine Specialists and Licensed Massage Therapists do not substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. It is my choice to receive Structural Medicine a form of therapy. I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they may adjust accordingly. I have stated my pertinent medical conditions, and will update the Structural Medicine Specialist/Massage 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 do nto hold my Structural Medicine Specialist/Massage 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*

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