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Intake form in social work Provider Name and Credentials Type of License Office Address City, ST Zip Code Child and Adolescent History Form The information requested in this form is treated as CONFIDENTIAL. The questions are

Massage therapy intake form Massage Therapy Client Health Intake Form Patient Information Name Address City State Zip Home Phone Work/Cell Phone E-mail Occupation Date of Birth Emergency Contact Person Phone Are you currently under a physicians care for an acute or chronic illness Y N If yes please explain If yes who is your health care provider Have you received a massage before Y N If yes when How did you hear about me What are your goals for this session Please list areas of tension stress and/or pain you wish to be addressed Health Information Please mark an X by all current conditions and P for all past conditions Abdominal /digestive problems Allergies Anxiety Arthritis/tendonitis Asthma or lung cond. Athletes foot Blood clots Chronic pain Circulatory/heart Constipation/diarrhea Depression Diabetes Fatigue Headaches migraine Hearing problems Hernia High blood pressure Jaw pain/TMJ pain Low blood pressure Muscle/bone injuries Muscle/joint pain Numbness/tingling Pregnancy Rash/fungus Sinus problems Sleep difficulties Spinal disorders Sprain/strain Tension/stress Vision problems Varicose veins Other Elaborate on noted areas above Please list your stress-reduction activities hobbies exercise and/or sport participation Please use the letters provided in the key to identify the symptoms you are feeling today. Circle the area around each letter representing the size and shape of each symptom location* P pain or tenderness S joint or muscle stiffness N numbness or tingling I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. I will inform my health care provider and massage therapist if anything changes in my status. I understand that massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension spasm or pain and to increase circulation* If I experience any pain or discomfort I will immediately inform my massage therapist so that the pressure and/or methods can be adjusted to my comfort level* I understand that my massage therapist does not diagnose illness or disease nor perform any spinal manipulations and does not prescribe any medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services. If I am unable to attend my scheduled appointment I will respect and abide by the set cancellation policies. Sexual advances request for sexual favors and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated* I understand that I am receiving massage therapy at my own risk. In the event that I become injured either directly or indirectly as a result in whole or in part of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist their principals and agents from all claims and liability whatsoever. Athletes foot Blood clots Chronic pain Circulatory/heart Constipation/diarrhea Depression Diabetes Fatigue Headaches migraine Hearing problems Hernia High blood pressure Jaw pain/TMJ pain Low blood pressure Muscle/bone injuries Muscle/joint pain Numbness/tingling Pregnancy Rash/fungus Sinus problems Sleep difficulties Spinal disorders Sprain/strain Tension/stress Vision problems Varicose veins Other Elaborate on noted areas above Please list your stress-reduction activities hobbies exercise and/or sport participation Please use the letters provided in the key to identify the symptoms you are feeling today. Circle the area around each letter representing the size and shape of each symptom location* P pain or tenderness S joint or muscle stiffness N numbness or tingling I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge.

Psychotherapy online form Disclosure Forms Client Psychotherapy Intake Form Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.

Massage form Massage Intake Form - CONFIDENTIAL INFORMATION WELCOME I would like to make your appointment as pleasant and comfortable as possible. If at any time you have questions regarding your session please let me know. Name Date of birth Address State City Home Phone Work Phone Occupation Have you ever received massage therapy Yes No Type of massage experienced swedish shiatsu deep tissue etc* Are you currently taking any medications If yes please list name and reason for medications Please review this list and check those conditions that have affected your health either recently or in the past. Place a check mark next to the condition* arthritis diabetes blood clots broken/dislocated bones bruise easily cancer chronic pain constipation/diarrhea auto-immune condition hepatitis A B C other skin conditions stroke surgery TMJ disorder depression panic disorder other psych condition diverticulitis headaches heart conditions back problems high blood pressure insomnia muscle strain/sprain pregnancy scoliosis seizures whiplash chemical dependency alcohol drugs AIDS fibromyalgia chronic fatigue lupus etc* If any of the above needs to be detailed or if there is anything else to share please do so Do you have any of the following today skin rash cold/flu anything contagious open cuts severe pain injuries/bruises Do you have any allergies to medications foods nuts etc* environmental allergens dust pollen fragrances reactions to skin care products Are you wearing contact lenses hearing aid hairpiece Please indicate with an X if any the areas in which you are feeling discomfort What are your goals/expectations for this therapy session The following sometimes occurs during massage. They are normal responses to relaxation* Trust your body to express what it needs to need to move or change position sighing yawning change in breathing stomach gurgling emotional feelings and/or expression movement of intestinal gas energy shifts falling asleep memories Please read the following information and sign below 1. I understand that although massage therapy can be very therapeutic relaxing and reduce muscular tension it is not a substitute for medical examination diagnosis and treatment. 2. This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment. 3. Being that massage should not be done under certain medical conditions I affirm that I have answered all questions pertaining to medical conditions truthfully. If at any time you have questions regarding your session please let me know. Name Date of birth Address State City Home Phone Work Phone Occupation Have you ever received massage therapy Yes No Type of massage experienced swedish shiatsu deep tissue etc* Are you currently taking any medications If yes please list name and reason for medications Please review this list and check those conditions that have affected your health either recently or in the past. Place a check mark next to the condition* arthritis diabetes blood clots broken/dislocated bones bruise easily cancer chronic pain constipation/diarrhea auto-immune condition hepatitis A B C other skin conditions stroke surgery TMJ disorder depression panic disorder other psych condition diverticulitis headaches heart conditions back problems high blood pressure insomnia muscle strain/sprain pregnancy scoliosis seizures whiplash chemical dependency alcohol drugs AIDS fibromyalgia chronic fatigue lupus etc* If any of the above needs to be detailed or if there is anything else to share please do so Do you have any of the following today skin rash cold/flu anything contagious open cuts severe pain injuries/bruises Do you have any allergies to medications foods nuts etc* environmental allergens dust pollen fragrances reactions to skin care products Are you wearing contact lenses hearing aid hairpiece Please indicate with an X if any the areas in which you are feeling discomfort What are your goals/expectations for this therapy session The following sometimes occurs during massage.

Client intake form massage I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that the american massage therapy association has provided this form as a reference and is not held liable for any services provided. signature assignment of benefits I am responsible for all charges for all service provided. In the unfortunate event that my insurance company denies payment or makes a partial payment contracted with my insurance company at a discount rate for services the amount remaining will be waived and I will not be asked to pay the balance. I authorize and direct payment of medical bene ts to my massage therapist for services billed. signature of parent or legal guardian if client if a minor release of medical records I authorize the release of medical records or other health care information including intake forms chart notes reports correspondence billing statements and other written information to my attorneys healthcare providers and insurance case managers for the purposes of processing my claims. I understand that the american massage therapy association has provided this form as a reference and is not held liable for any services provided. signature assignment of benefits I am responsible for all charges for all service provided. In the unfortunate event that my insurance company denies payment or makes a partial payment contracted with my insurance company at a discount rate for services the amount remaining will be waived and I will not be asked to pay the balance. I authorize and direct payment of medical bene ts to my massage therapist for services billed. signature of parent or legal guardian if client if a minor release of medical records I authorize the release of medical records or other health care information including intake forms chart notes reports correspondence billing statements and other written information to my attorneys healthcare providers and insurance case managers for the purposes of processing my claims. employer s name/school name phone primary insurance plan name group number plan number Please inform your practitioner immediately upon signing any exclusive Release of Medical Records with your attorney that may impact the above release statement. Client intake form client signature date of initial visit personal information current health Do you exercise regularly and/or participate in any sports r Y name rN If yes what kind of exercise/sports address state home phone Do you perform any repetitive movement in your work sports or hobby zip rY Are you experiencing tension sti ness discomfort or pain r Y city cell phone If yes describe Do you sit for long hours at a workstation computer or driving work phone email occupation Do you experience stress in your work family or other aspect of your life marital status referred by emergency contact name physician s name Have you recently had an injury surgery or areas of in ammation Do you have sensitive skin Do you have any allergies to oils lotions or ointments massage experience Have you had a professional massage before r Yes r No If yes what types of massage have you had swedish shiatsu deep tissue etc. How long have you been receiving massage therapy If yes please explain List any medications you are currently taking Frequency of massages What are your goals for treatment List any known allergies health history Musculoskeletal Bone or joint disease Tendonitis/Bursitis Arthritis/Gout Jaw Pain TMJ Lupus Spinal Problems Migraines/Headaches Osteoporosis Circulatory Heart Condition Phlebitis/Varicose Veins Blood Clots High/Low Blood Pressure Lymphedema Thrombosis/Embolism Respiratory Breathing Di culty/Asthma Emphysema Allergies specify Nervous System Shingles Numbness/Tingling Pinched Nerve Chronic Pain Paralysis Multiple Sclerosis Parkinson s Disease Reproductive Pregnant stage Ovarian/Menstrual Problems Prostate Skin Rashes Cosmetic Surgery Athlete s Foot Herpes/Cold Sores Digestive Irritable Bowel Syndrome Bladder/Kidney Ailment Colitis Crohn s Disease Ulcers Other Cancer/Tumors Diabetes Drug/Alcohol/Tobacco Use Contact Lenses Dentures Hearing Aids Any other medical condition s not listed Please explain any of the conditions that you have marked above Psychological Anxiety/Stress Syndrome Depression This form was created as a resource by the american massage therapy association and they are not held liable for any services provided. client agreement health release form insurance information client s full name date ins. ID date of injury Is your condition the result of an auto accident If so in what state did the accident occur r A work injury r A health condition r Other What type of insurance do you have that may cover you for this condition check all that apply r Auto r Workers compensation/state Industrial r Liability r Health Was a police/accident report led Client s relation to insured r Self r Spouse r Partner r Child r Other insured s full name date of birth r Male r Female r Single r Married r Partnered r Other It is my choice to receive massage therapy.

Counseling intake forms sample... CLIENT INTAKE FORM Please provide the following information for our records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality

Cpca short intake form CLIENT INTAKE FORM Name: Address: Phone: Home #: Work #: Cell #: Email: What time and day is best? Okay to leave a phone message? Yes No Text message/Email? Yes No Age Date of Birth Occupation: Marital

Form therapeutic Client Intake Form Therapeutic Massage Personal Information Name Phone Day Date of Birth Address City/State/Zip email Emergency Contact Phone Eve Occupation Phone The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge. Date of Initial Visit 1. Have you had a professional massage before Yes No If yes how often do you receive massage therapy 2. Do you have any difficulty lying on your front back or side If yes please explain 4. Do you have sensitive skin 5. Are you wearing contact lenses dentures a hearing aid 6. Do you sit for long hours at a workstation computer or driving If yes please describe 7. Do you perform any repetitive movement in your work sports or hobby 8. Do you experience stress in your work family or other aspect of your life If yes how do you think it has affected your health muscle tension anxiety insomnia irritability other 9. Is there a particular area of the body where you are experiencing tension stiffness pain or other discomfort Yes Circle any specific areas you would like the massage therapist to concentrate on during the session Continued on page 2 Medical History In order to plan a massage session that is safe and effective I need some general information about your medical history. 11. Are you currently under medical supervision 12. Do you see a chiropractor If yes please list 14. Please check any condition listed below that applies to you contagious skin condition phlebitis easy bruising joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis open sores or wounds recent accident or injury recent fracture recent surgery artificial joint sprains/strains current fever swollen glands allergies/sensitivity heart condition high or low blood pressure circulatory disorder varicose veins atherosclerosis deep vein thrombosis/blood clots osteoporosis epilepsy headaches/migraines cancer diabetes decreased sensation back/neck problems Fibromyalgia TMJ carpal tunnel syndrome tennis elbow pregnancy If yes how many months Please explain any condition that you have marked above 15. Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you Draping will be used during the session only the area being worked on will be uncovered* Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session* Informed written consent must be provided by parent or legal guardian for any client under the age of 17. I print name understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension* If I experience any pain or discomfort during this session I will immediately inform the therapist 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 chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of* I understand that massage therapists 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 given should be construed as such.

Energy intake form csd 43 engl... Department of Community Services and Development 0 Energy Intake Form CSD 43 (12/2014) Priority Points: 0 0 0 A.C.C. Job Control Code Intake Initials: Agency: First Name Intake Date: Eligibility Cert

Lymphedema intake form Lymphedema Intake Form Please fill out the following information to the best of your ability. Answer only those questions that are applicable to you. The information will be further discussed as necessary during your evaluation* Name Birthdate // Date // Referring Physician Reason for visit SOCIAL HISTORY Home Environment Apartment One story home Multi level home Assisted living/Nursing Facility Lives alone Lives with Other Occupation Retired Employed as Other Leisure Activities/Hobbies Do you have any limitations in range of movement Yes / No What are they If yes what are they Do you require assistance with getting washed/dressed Yes / No CURRENT and PAST MEDICAL HISTORY Check all that apply Infection in affected limb/area ie. Cellulitis If current are you taking antibiotics Yes / No Aortic Aneurysm Arthritis Osteo Rheumatoid Gout Asthma / COPD / Respiratory Problems Blood Pressure High Low Controlled Cancer Where Circulatory Problems Arterial Venous Raynaud s syndrome Varicose Veins Diabetes Controlled Uncontrolled Heart Problems Congestive Heart Failure When Heart Attack When Bypass surgery / Stents When Irregular heartbeat / A fib Pacemaker Infections/Chronic Diseases ie. Hepatitis TB HIV/AIDS Pain Syndrome RSD/Chronic Regional Pain Syndrome Shingles Neuropathy Where Other Blood Clot / Pulmonary Embolism Epilepsy / Seizure Disorder Kidney Problems Thyroid Problems Hyper/High Hypo/Low Pregnancy C Section s Yes / No Stroke When Connective Tissue Disorder ie. Lupus scleroderma etc* Gastrointestinal GI Problems Surgeries List type and date Depression / Anxiety Hearing or Vision Problems History of fractures burns or other injuries to affected limb s /area Yes / No Other health conditions/problems not listed If you have a history of cancer Type Location Surgery Yes / No If surgery type of surgery/date s Reconstruction Yes / No Lymph nodes removed Yes / No of nodes removed of nodes positive for cancer Have you had Chemotherapy Yes / No If yes dates Radiation Yes / No If yes of treatments Date completed List all current Medications and Allergies See attached list LATEX ALLERGY ADHESIVE ALLERGY EDEMA/LYMPHEDEMA HISTORY Do you have swelling Yes / No Location of swelling When did your swelling begin Does it go down at night Yes / No What makes it worse Better Have you had previous treatment for your swelling Yes / No When/Where Do you use or have you used any of the following to manage your swelling Compression garment ie. socks sleeve etc* Compression pump Bandaging self massage Diuretics/ water pills Elevation/Exercise Other Do you have any wounds Yes / No Where Who is currently treating your wounds St Mary s Wound Center Other OTHER INFORMATION Severity of pain Circle selection 0 no pain 10 worst possible 0 1 2 3 4 5 6 7 8 9 10 Describe the pain What makes your pain better What makes your pain worse How do you rate your overall health status Excellent Very good Fair Poor How do you learn best Reading Listening Demonstration Pictures Other What are your goals for therapy Are you being treated by any other medical professionals Yes / No If Yes please list Are you currently receiving Home Health Services ie.

Referral intake form swedish h... SWEDISH DIGESTIVE HEALTH NETWORK Arnold Pavilion, 1221 Madison St., Suite 1220, Seattle, WA 98104 T 2062158178 1855411MyGi (6944) F 2062153525 www.swedish.org/digestive REFERRAL INTAKE FORM (To be

Esthetician client intake form... Get Instant Access to eBook Esthetician Client Intake Form PDF at Our Huge Library ESTHETICIAN CLIENT INTAKE FORM PDF Download: ESTHETICIAN CLIENT INTAKE FORM PDF ESTHETICIAN CLIENT INTAKE FORM PDF

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