Harborview Health & Wellness Intake Form

Today's Date

MonthDayYear

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Best E-Mail

example@example.com

Best Phone Number

Area CodePhone Number

We would like to email you based on your choices below (check all that apply):

Were you referred by someone? If so, whom? (If no referral, input NA.)

Are you a UnityPoint Employee/First Responder?

If you are a UnityPoint Employee/First Responder, which Department are you with?

Have you had a professional massage before?

Have you had a Reflexology appointment before?

If "Yes," how recently was your last massage/reflexology appointment? (Skip this question if you've never before had a massage/reflexology appointment.)

Why did you leave your last massage therapist/reflexologist? (If you've never had a professional massage/reflexology appointment, skip this question.)

Do you have any allergies or skin sensitivities to oils or lotions?

If you answered "Yes" to the previous question, what has/have been your experience(s) when you reacted to an oil or lotion? (If you've had no reaction, enter N/A.)

Are you currently wearing or have you had implanted:

Do you sit for long hours (e.g.: driving, at a workstation, or a computer)?

How would you rate your pain/stress/discomfort today? On a scale of 1-10, 1 being "terrible" and 10 being "feel great"

What is your goal for today's appointment?

Please enter any medications (prescription or over-the-counter) you are currently taking or have taken in the past few weeks. If you have not taken any meds, please enter N/A.

Please identify any condition below that applies to you:

Please explain any condition(s) you identified above. If no issues were identified, enter N/A.

Is there anything else about your health history that you think would be useful for your massage therapist/reflexologist to know? If not, enter N/A.

Please identify which area you would like your massage therapist to concentrate on during your session.

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware or suspect.

I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session or provided on this Intake Form should be construed as such.

Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand there shall be no liability on the practitioner’s part should I fail to do so.

Understanding all of this, I give my consent to receive care. I understand that by clicking "Submit" on this page, it is the same as my handwritten signature and it is legally binding.

Signature

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