Booking & Intake Form

Booking & Intake Form
Patient Information
Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Gender*
Phone Number*
Email*
example@example.com
Occupation
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Phone Number
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? *

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Unbearable
When did you start experiencing this problem?*

MonthDayYear
Date
Health Condition

HypertensionHeart issuesRashesDiabetes MellitusBone problemsBlood ClootingSpams/CrampsSprainsVaricose VeinsConstipationArthritisSeizureSpinal Cord IssuesChronic coughAsthmaNeck painBack painHips painLegs painInfectious diseasesVision problemKidney disorder
Are you pregnant, breastfeed, or nursing? (Female)*

YesNoN/A
If yes, how many weeks?*
Do you exercise daily?*

YesNo
What type of exercises you do?*

StrenuousModerateLightNone
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?*

NumbnessSharp painTinglingBurningDull painStiffnessN/A
Have you have family history of the following medical diagnosis?*

Cardiovascular diseaseDiabeter MellitusCancerAsthmaArthritisN/AOther
Are you interested in any add-on services? Mark all that apply and we can discuss further.*

Couples massageSound TherapyGraston / Fascia ScrapingCuppingHot Stone
How did you hear about me?*

GoogleYelpI was referredI 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.
Should be Empty:

Booking & Intake Form

Patient Information

Medical Data

Authorization and Consent