JLM Therapeutics LLC
Client Intake Form
1633 Fillmore Street, Suite 114
Denver, Co 80206 | 720-935-9980
www.jlmtherapeutics.com
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
How Did you Hear About Us?
*
Website
Social Media
Groupon/ClassPass/Living Social
Walk By
Referral - please note who referred you
Referred By
Side Dominance
*
Right
Left
Preferred Pronouns
*
He/Him/His
She/Her/Hers
They/Them/Theirs
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Emergency Contact Relationship
*
Occupation
*
Have you had massage and/or yoga therapy in the past?
*
Yes
No
If yes, how recently and how often?
What are your physical goals for today’s session? What are your mental/emotional goals as well, if any?
*
What are the top three places on your body you want to address in our time together?
*
What sort of massage pressure do you prefer?
*
Light/Swedish
Medium/Deep Tissue
Medium/Ashiatsu
Hard/I want to feel sore the next few days
Do you practice yoga?
*
Yes
No
If yes, what sort of yoga do you practice?
How do you sleep in general?
*
How are you feeling today?
*
Health Conditions
Please check the category and mark any conditions plus list treatments for those conditions. Use the body diagram to mark areas of past physical ailments, injuries and surgeries as well as any muscle and/or joint pain, stiffness, numbness, tingling, swelling, bone breaks, sprains, strains, skin bruising, sensitivity, rashes, or infections
Structural - include details on the body diagram below
arthritis
osteopenia
osteoporosis
scoliosis
broken bones
dislocations
surgeries
injections
acne
skin rashes
boils
abscesses
herniations
implants
infections
sprains
discomfort/pain
edema
neuropathy
rashes
infection
cancer
Please Show Any Areas of Concern (Pain, Surgery, Etc)
Reproductive
pregnancy
period
endometriosis
prostate enlargement
testicular pain
penis pain
painful intercourse
pelvic floor dysfunction
infections
cancer
Digestive
Crohn’s
IBS
diabetes
gas
bloating
constipation
diarrhea
intestinal polyps
kidney disease
infections
incontinence
cancer
Circulatory
heart disease
arrhythmia
arteriosclerosis
pacemaker
stint
shunt
stroke
varicose veins
blood clots
infections
high/low blood pressure
cancer
Respiratory
asthma
COPD/emphysema
smoking
infections
COVID
cancer
pneumonia
Neurological
Sciatica
MS
Parkinson’s
Fibromyalgia
epilepsy
seizures
headaches
migraines
dizziness
memory loss
confusion
overwhelm
infections
cancer
Ocular
Lasik
glaucoma
farsightedness
infections
nearsightedness
retinal detachment
pink eye
cancer
Endocrine
edema
allergies
thyroid
testosterone
estrogen
adrenaline
infections
cancer
swollen lymph nodes
Psychosocial
anxiety
depression
loneliness
constantly active
agoraphobia
alcohol
recreational drug use
pharmaceutical drug use
non-recreational drug use
Is there any condition not listed above or information you think I should know in regard to your health, your progress or your care?
Submit
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