Rx Massage & Personal Training Intake Form

Rx Massage & Personal Training Intake Form

All information is held confident. At no given point is information disclosed or shared without client’s written consent.
Date

MonthDayYear
Date
Full Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Information
Medications
Allergies
1. Areas of discomfort/pain
2. Onset of discomfort/pain
3. Rate of Pain

1

2

3

4

5

1 is Very Little, 5 is Very Painful
4. Frequency

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

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?
10. Is there anything you do that creates, increases or decreases pain?
11. What are the physical duties required of your occupation?
12. Are you currently seeing any other healthcare professional?
Please check any symptoms that apply:
Head Symptoms

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

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 Symptoms

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

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 Symptoms

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

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 Symptoms

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 Symptoms

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
Client information are confidential and written authorization is required to release any information.

We do not double book appointments

Please reschedule session if more than 15 minutes late

24 hour cancellation notice is required

You will have a consultation with your provider to discuss the session

You my 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

Client Agreement:

I understand that personal training, stretch and corrective exercise does not diagnose and heal illness, disease, any physical or mental disorder.

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

I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction.

I understand that at any time I feel pain or discomfort during the session, I will immediately inform my practitioner.

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

By my electronic signature below, I agree to the Rx Massage and Personal Training policy and client agreement above.
Signature*

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Rx Massage & Personal Training Intake Form

Health Information