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Client Health Intake Form

Please fill out new intake on your visit to ensure proper service and update your health history.~TAO JOY

Today’s Date:

Client Name:

Please fill out this field.

Date of Birth:

Gender:

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Address:

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Phone:

Please enter a phone number.

Email:

Please enter a valid email address.

Referred by:

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Emergency Contact Name:

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Emergency Contact Phone:

Please enter a phone number.

Physician/Health-care Provider Name:

Please fill out this field.

Physician/Health-care Provider Phone:

Please enter a phone number.

Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?

Yes

Do you have a physician referral/prescription?

Yes

Are you seeking insurance reimbursement (If yes, please complete the Billing Information form)?

Yes

Type of insurance coverage for this claim:

Car Collision

Worker’s Compensation

Private Health

Have you ever received professional massage/bodywork before?

Yes

If Yes, How recently?

Please fill out this field.

What types of massage/bodywork do you prefer?

Please fill out this field.

What kind of pressure do you prefer?

Light

Medium

Firm

What are your goals/expected outcomes for receiving massage/bodywork?

Please fill out this field.

How do you feel today?

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List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

Please fill out this field.

Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?

Yes

If yes, explain

Please fill out this field.

Are you wearing contacts?

Yes

Are you wearing dentures?

Yes

Are you wearing a hairpiece?

Yes

Are you pregnant? If yes, please note, we only massage clients at 15 weeks or more.

Yes

Have you had any injuries or surgeries in the past that may influence today’s treatment?

Please fill out this field.

Select any of the following health conditions that you currently have (If you are unsure, please ask. Please answer honestly, as massage may not be necessary):

Blood clots

Infections

Congestive heart failure

Contagious diseases

Pitted edema

Please indicate if you have or have had the following conditions: Muscle or joint pain

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Numbness or tingling

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Swelling, Edema or inflammation

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Bruise easily or Anemia

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Sensitive to touch/pressure or skin irritations

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: High or Low blood pressure

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Stroke, heart attack or aneurysm

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Varicose veins or Vascular issues

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Shortness of breath or breathing problems

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Cancer Any Time/Type

Current

Past

Not Applicable

Please indicate if you have or had the following conditions: Neurological (e.g. MS, Parkinson’s, chronic pain) or cognitive disorders

Current

Past

Not Applicable

Please indicate if you currently have or have had the following conditions: Epilepsy, seizures or convulsing

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Headaches, Migraines or Sinus issues

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Dizziness, ringing in the ears, or Tinnitus

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Digestive conditions (e.g. Crohn’s, IBS)

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Gas, bloating, constipation or gastrointestinal issues

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Kidney disease, infection or disfunction

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Arthritis (rheumatoid, osteoarthritis, ect.) or Tendinitis

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Osteoporosis, degenerative spine/disk

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Scoliosis/Stenosis

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Any broken bones/fractures

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Allergies or Asthma

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Diabetes/Low Blood Sugar

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Endocrine/thyroid conditions

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Depression, anxiety

Current

Past

Not Applicable

Please indicate if you have or have had the following conditions: Memory Loss, confusion, easily overwhelmed

Current

Past

Not Applicable

Please fill out this field.

Write your full name below for signature

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Enter today's date

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Write your full name below for signature (sign for minors >18 yrs old)

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Enter today's date (in case of a minor)

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