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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

Patient bintake formb mid peni... Mid Peninsula Endoscopy Center Patient Intake Form (Please print or write legibly) I. PATIENTS INFORMATION Last Name First Name M.I. Do you go by any other names: YES or No If so, what are they Date

Printable intake forms mid ohi... DATE Mid-Ohio Sleep Services, Inc. REFERRING PHYSICIAN 7811 Flint Road, Suite C Columbus, Ohio 43235 (614) 433-2000 PRIMARY CARE PHYSICIAN John L. Eickholt, M.D. Board Certified Neurologist Board

Specialty behavioral health in... SPECIALTY BEHAVIORAL HEALTH - INTAKE FORM This information you provide will be used to plan your treatment and is held strictly confidential. You may leave any item blank if you don't feel comfortable

Child intake form pitts amp as... Child Intake Form Child s Name (listed on insurance) Child is called: Date of Birth: Social Security Number: Male Female Street Address: City: State: Zip: Phone #1: name listed under? (#1 used for

Ocl intake form and instructio... Ministry of the. Attorney. General. Office of the. Children's. Lawyer. Intake Form Instructions. Custody/Access Cases under the Divorce Act and/or the. Children'sLaw Reform Act. Please read this page

Get 287920577 form SIMPLE WILL INTAKE FORM for Poklemba & Hobbs, LLC PLEASE READ. In a Simple Will, except for specific bequests (see below), your entire estate will either go to your spouse, or to your children,

Occupational therapy intake fo... Pediatric Information Form Patient Name: Date of Birth: Age: M F Ethnicity: Preferred Language: Current Diagnosis (if any): Home Address: Primary Phone: School Attended: Teacher: Grade: School Phone:

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