Medical Massage Client Intake Form Medical Massage Client Intake Form
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- Bernard Bradford
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1 Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you. 1. Are you over the age of 18? YES NO 2. What is the reason for your visit today? 3. What is your main complaint? 4. When did your symptoms first occur? 5. On the scale below, please circle the severity of your main complaint (at it s worst): None Slight Mild Moderate Severe 6.On the scale provided below, please circle the percentage of time you experience your complaint: 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Occasional Intermittent Frequent Constant 7. How long have you been experiencing your main complaint? 8. When do you notice is most? AM PM About how long does it last? Mins. Hrs. 9. Is there anything that makes it feel better? 10. Is there anything that makes it feel worse? 11. Does this problem interfere with your sleep? YES NO 12. Have you lost time at work because of it? YES NO 13.Have you been treated for this before? YES NO If yes, by who? When and/or how long ago did you receive treatment? Was there a diagnosis given? YES NO If yes, what: Was the treatment helpful? Please explain: 1 of 6
2 14.Have you ever been x-rayed or received MRI, CAT scan in the past months? YES NO If yes, when? If yes, are you cleared to receive massage by your doctor? YES 15.I have: Been hospitalized or had surgery. If yes, please list below: NO Type of Hospitalization/Surgery: Approx. Date: Type of Hospitalization/Surgery: Approx. Date: 16.Do you wear a heel lift? YES NO If yes, which side? Right Left How long have you worn it? 17.Please list all prescription medications you are currently taking (if you know, please include the reason for taking these): 18.Please list all of the over-the-counter medications/supplements you are currently taking (if you know, please include the reason for taking these): 19.Have you ever had? Motor Vehicle Injury Sports Injury Work Injury Slip & Fall Injury If yes, please explain: 20.What activities do you do at work? Sit: Most of the day Half of the day A little of the day Stand: Most of the day Half of the day A little of the day Computer work: Most of the day Half of the day A little of the day On the phone: Most of the day Half of the day A little of the day 21.What activities do you do outside of work? 22.What habits do you currently have? 2 of 6
3 Smoking: Packs/Day Alcohol: Drinks/Week Coffee/Caffeine: Cups/Day Poor Diet: Fast/Fatty Foods high sugar/carb intake skipping meals High Stress level: Reason: 23.Female only: are you or could you be pregnant? YES NO Due date if yes: PLEASE FILL OUT THE NEXT THREE SECTIONS AS THEY APPLY TO YOU: How would you describe the pain? Lower Back Pain Does your pain radiate into other areas? YES NO If yes, where? Do you ever have numbness or tingling in the legs? YES NO Explain: Neck Pain How would you describe the pain? Do you feel pressure or pain behind your eyes? YES NO Does the pain radiate to the arm? YES NO If yes, where? Do you have difficulty lifting or turning your head? YES NO If yes, in which direction(s) : Right Left Up Down Headaches Do you get headaches? YES NO Frequency: Do you have any known triggers for headaches? YES NO If yes, please list: Does pain or cracking in your jaw accompany your headaches? YES NO Check those activities below during which you experience difficulty or pain: Lying on back Getting in/out of car Pulling Sitting Standing for long periods Lying on side Dressing self Reaching Bending forward Sneezing Turning over in bed Kneeling Coughing Bending backward Pushing Stooping Walking Lifting Driving Recreation Concentrating Working Other: Lying flat on stomach 3 of 6
4 Please check any additional complaints that you may have: Anxiety Fractures Loss of balance Rheumatoid Arthritis Arthritis Gout Low back pain/stiffness Right/Left shoulder pain Anemia Heart Disease Mid back pain Right/Left arm pain Cancer Heavy feeling of head Migraine Headaches Right/Left leg pain Cold feet Hernia Mood Swings Ringing in ears Cold hands Herniated disk Neck motion restriction HIV (AIDS) Diabetes High blood pressure Neck stiffness Shortness of Breath Dizziness Hypertension Osteoporosis Upper Back Pain/stiffness Eyes sensitive to light Insomnia Pain behind eyes Vision Problems Fatigue Jaw pain Pinched nerve Hot Flashes 24.Please list any other complaints, infectious diseases and/or allergies here: 25.[optional] Please list any other pertinent information that you think we should know about: 4 of 6
5 26.On the diagram below, please show where you are experiencing all of your present complaints using the following letters: A. ache B. burning pain C. cramping D. dull pain R. throbbing pain N. numbness T. tingling FEMALE MALE *Please note that areas covered with a dark spot will not be treated. Only the areas being treated will be uncovered. Draping will be used during the massage session unless otherwise agreed to by both the client and therapist. 5 of 6
6 Client Acknowledgement Please acknowledge that you have read and understand the following information by initialing each statement. 1.I understand that massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I am unsure about or need diagnosis for. 2.I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals and does not perform any spinal adjustments. 3. I understand that if I have a serious medical diagnosis, and am unsure if I should receive massage, I need to provide a physician s written consent prior to services. 4.I understand that spa d sante (SDS) does not tolerate the making of sexual advances or comments. The company policy allows any therapist or client to end a treatment at any time if he or she feels uncomfortable or when in doubt, he/she also has the option to leave the door open during treatment. 5.I also understand that I must inform the therapist of any changes to my health. I,, have read and understand the information provided on this sheet. Please print your name Signature Date Please provide your address below if you would like to be added to our mailing list to receive Address: special promotions and discounts. SDS Health & Wellness Centers take great care to ensure our clients privacy. We do not share client information unless express written consent it provided by the client. Your privacy and comfort is of the utmost importance to us. We appreciate your patronage and we look forward to assisting you on your journey to good health! 6 of 6
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Name: Mowry Chiropractic Inc. 240 North Liberty Street, Powell, OH 43065 (614) 436-9070 (p) ~ (614) 436-8803 (f) PERSONAL INJURY CASE HISTORY 1. Circle the severity (0 = No Pain to 10 = Very Severe Pain)
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.
AON Physical Therapy & Wellness
AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?