Heavy Mettle Kinetic Therapy Intake Form
Personal Information
Name
First Name
Last Name
Phone number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
D.O.B
-
Month
-
Day
Year
Date
Occupation
Employer
Email address
example@example.com
GP Name and Address
Emergency Contact
Relationship
Contact number
How did you hear about us?
MedicalInformation
Injury history/background: Pleaseshare information about your injury or injuries including when it/they began
Surgical history/background: Please share information about surgeries or operations you've had including dates.
Are you taking medication? Yes/No (Please circle) If yes, please list name and frequency of use
Are you currently pregnant? Yes/No (Please circle) If yes, how many months?
-
Month
-
Day
Year
Date
Due date:
-
Month
-
Day
Year
Date
Are you you currently under medical supervision or receiving other medical interventions? Yes No
If yes, please describe
Please indicate any of the following that apply to you.
Conditions
Areas of swelling
Autoimmune disorder
Back / neck problems
Bleeding disorders
Blood clots Bruise easily
Bursitis Cancer
Contagious condition
Decreased sensation
Diabetes
Fibromyalgia
Headaches
Heart condition
Hypertension
Kidney disease
Multiple sclerosis
Neurological condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendinitis
TMJ disorder
Varicoseveins
Vertigo/dizziness
Massage Information
Do you have any allergies or sensitivities? Yes No If yes, please explain.
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Heavy Mettle Kinetic Therapy Intake Form
Massage Information
What are your goals for this treatment session?
Please circle any areas of discomfort
Lifestyle Information
Do you exercise regularly
Yes
No
If yes, how many days per week do you exercise?
What type of training do you do? (Bodybuilding, CrossFit, Weightlifting etc)
Are you on a calorie controll diet?
Yes
No
How many calories do you intake daily?
How many litres of water do you intake daily?
Do you consume alcohol
Yes
No
If yes, how many units per week?
How would you describe your stress levels?
Medium
High
Low
How would you describe your energy levels?
Medium
Low
High
How would you describe your sleep pattern?
What do you do for relaxation?
By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy, I am aware bruising and red pete- chiae may appear on the skin and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.
Client signature
Date
-
Month
-
Day
Year
Date
Kinetic Therapist-signature
Date
-
Month
-
Day
Year
Date
Marketing Information
I confirmthat I wouldliketoreceiveemail marketing communications about Kinetic Therapies news and promotions.
Yes
No
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