New Client Intake Form
Patient Information
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Non-binary
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Medical Data
Do you have any allergies? (I.e. Lotions, essential oils, latex, etc.) Please list all that may apply.
Are you currently experiencing pain in any part of your body? If yes, please indicate what body part. Please be specific.
*
In scale of 1-10, how much pain are you feeling right now?
*
No Pain
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is No Pain, 10 is Unbearable
When did you start experiencing this problem?
*
-
Month
-
Day
Year
Date
Health Condition
Hypertension
Heart issues
Rashes
Diabetes Mellitus
Bone problems
Blood Clooting
Spams/Cramps
Sprains
Varicose Veins
Constipation
Arthritis
Seizure
Spinal Cord Issues
Chronic cough
Asthma
Neck pain
Back pain
Hips pain
Legs pain
Infectious diseases
Vision problem
Kidney disorder
Are you pregnant, breastfeed, or nursing? (Female)
*
Yes
No
N/A
If yes, how many weeks?
*
Do you exercise daily?
*
Yes
No
What type of exercises you do?
*
Strenuous
Moderate
Light
None
Are you wearing any implantable medical devices? If yes, what are these devices?
*
Are you currently taking any medications? If yes, please list them below:
Were you previously hospitalized? If yes, please indicate when and why:
*
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
*
What type of pain are you experiencing?
*
Numbness
Sharp pain
Tingling
Burning
Dull pain
Stiffness
N/A
Have you have family history of the following medical diagnosis?
*
Cardiovascular disease
Diabeter Mellitus
Cancer
Asthma
Arthritis
N/A
Other
Are you interested in any add-on services? Mark all that apply and we can discuss further.
Couples massage
Sound Therapy
Graston / Fascia Scraping
Cupping
Hot Stone
How did you hear about me?
*
Google
Yelp
I was referred
I came across your business card or other marketing material
Authorization and Consent
I confirm that all information given in this form is true, complete, and accurate.
I released this organization for any responsibility in case of accident, illness, or injury.
I acknowledge that no assurance was offered about the outcome.
Print Form
Submit
Should be Empty: