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Client Intake and Medical Questionnaire
Date picker
Therapist
(Required)
Client Name
(Required)
Date Of Birth
(Required)
Month
Month
Day
Year
Address
(Required)
Phone
(Required)
Email
(Required)
Yes, subscribe me to your newsletter.
Occupation
Emergency Contact
(Required)
Emergency Contact Phone
(Required)
Is this Massage/bodywork medically necessary (medical condition, injury, surgery)
(Required)
Yes
No
Do you have physician referral/prescription?
Yes
No
Are you seeking insurance reimbursement?
Yes
No
Have you ever received massage/bodywork in the past
(Required)
Yes
No
How Recently?
What types of massage/bodywork do you prefer?
(Required)
What kind of pressure do you prefer?
(Required)
Light
Medium
Firm
What are your goals/expected outcomes from treatment?
How do you feel today?
List and prioritize your current symptoms (stress, pain, stiffness, numbness. tingling, swelling, ect)
Do these symptoms interfere with you daily activities and lifestyle
Yes
No
Check if any of the following apply
Wearing contact lenses
Wearing a hairpiece
Wearing dentures
Pregnant
Please indicate any conditions that you have now, had in the past, or if not applicable
Muscle or Joint Pain/Stiffness
(Required)
Numbness or Tingling
(Required)
Swelling
(Required)
Bruise Easily
(Required)
Sensitive to touch/pressure
(Required)
High/Low blood pressure
(Required)
Varicose Veins
(Required)
Shortness of Breath
(Required)
Cancer
(Required)
Neurological (Multiple Sclerosis, Parkinson's, Epilepsy, Seizures)
(Required)
Headaches/MIgraines
(Required)
Dizness
(Required)
Allergies
(Required)
Digestive Issues (Crohn's, IBS, Gas, Bloating, Constipation)
(Required)
Arthritis (Rheumatoid, Osteoarthritis)
(Required)
Scoliosis
(Required)
Broken Bones
(Required)
Diabetes
(Required)
Thyroid Conditions
(Required)
Depression/Anxiety
(Required)
Memory Loss/Confusion
(Required)
Any other conditions you would like to make us aware of?
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