Medical Massage Client Intake Form Medical Massage Client Intake Form

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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:

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:

Medical Massage Client Intake Form

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If yes, when?

If yes, are you cleared to receive massage by your doctor? ❑ YES ❑ NO

15.I have:

Been hospitalized or had surgery. If yes, please list below:

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?

21.What activities do you do outside of 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

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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:

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:

Lower Back Pain

How would you describe the 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 ❑ Lying flat on stomach ❑ Pushing ❑ Stooping ❑ Walking ❑ Lifting ❑ Driving

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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:

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

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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

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Client Acknowledgement

Please acknowledge that you have read and understand the

following information by initialing each statement.

I, , have read and understand the information provided on this sheet.

Please print your name

Signature Date

Please provide your email address below if you would like to be added to our mailing list to receive special email promotions and discounts.

Email Address:

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.

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

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References

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