Intake Form

Name

Email Address

Sex Female Male

Age:

Occupation:

Primary Physician:

Emergency Contact:

Emergency Contact Relationship:

Emergency Contact Phone:

How did you hear about us?

Mobile visit or Office visit?

Are you okay with having your picture taken or a video? Yes No

Are you taking any medications? Yes No

Any surgeries in the past year?

Have you had any orthopedic injuries? Yes No

Are you currently pregnant? Yes No

If yes, how far along:

Do you suffer from chronic pain? Yes No

Any high risk factors?

Please check any of the following that apply to you:
Cancer
Headaches/Migranes
Arthritis
Diabetes
Joint Replacement
High/Low Blood Pressure
Neurotherapy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
None of the above

Are there any other conditions that not listed above? Yes No

Other important info related to conditions, pain, etc

Have you had a professional massage before? Yes No

What pressure do you prefer? Light - Medium Medium - Medium Deep
Deep

Do you have any allergies or sensitivities? Yes No
Not Sure

If yes, please list allergies or sensitivities:

What are your goals for this treatment session?

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