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New Client Intake Form
Please complete this form prior to your first appointment:
Name
*
First
Last
Date
*
MM slash DD slash YYYY
Current Gender
*
Male
Female
Other
Preferred Pronouns
*
He/Him/His
She/Her/Hers
They/Them/Theirs
Date of Birth
*
MM slash DD slash YYYY
Phone
*
Alternate Phone
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
referred by
*
In case of emergency contact
*
Emergency Phone
*
In the event we need to contact you regarding an appointment, which would you prefer?
*
Phone call
Text
email
Basic Health Information
Occupation
posture assumed most of the day
How often do you exercise?
Type of exercise
Height and Weight
*
What are primary stressors
*
job
family
finances
school
relationships
health
other
Are you basically in good Health
yes
no
Has there been any significant change to your health in the past year?
*
yes
no
Are you happy with your general energy level?
yes
no
Do you use any of the following regularly?
*
tobacco
chewing tobacco
alcohol
soft drinks
caffeine
fried foods
artificial sweetener
sleeping aids
prescription meds
Cannabis/marijuana
other recreational drugs
NSAID's
None
Please indicate if any of the following apply"
*
contact lenses
dentures
hearing aid
pacemaker
medication patch
pins, plates, artifical joints
lens implant
silicone implants
medication pump
other implants/ports
None
List medications, herbs, drugs:
*
What is your goal or concern for today's session?
Medial History
Indicate any of the following that apply in the last 6 months
*
acne
AIDS/HIV
allergies
anxiety
arthritis
asthma
blood pressure elevated
blood pressure low
blood clots
cancer
chronic fatigue/fibromyalgia
claustrophobia
constipation
persistent cough (esp the last 14 days)
depression
eye infections, such as pink eye, conjunctivitis
fever over 101 (esp the last 14 days)
fractures
fungal infections, such as athlete's foot, thrush
headache--sinus
headache--tension
headache--cluster
headache--migraine
headache--histamine
heart problems
hematomas/easily bruised
hepatitis
herpes
loss of sense of taste or smell (esp last 14 days)
menopause symptoms
nerve pain
numbness/tingling
nursing
PMS
Pregnant (currently)
psoriasis
rashes (esp in last 14 days)
strain/sprain
tendonitis
varicose veins
vomiting/nausea/diarrhea (last 14 days)
None
medication allergies
*
Food allergies
lotion, cream, oil allergies
*
Consents and Acknowledgments
Consent
*
I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so.
Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I understand I may be asked for a referral from my primary care provider prior to service being rendered if determined necessary by my therapist.
I realize it is my choice to receive massage therapy. I acknowledge that the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, increasing circulation, energy or lymphatic flow, or increasing mobility.
Acknowledgement
*
I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service.
I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations.
Release of Information
*
I hereby authorize you to release to the practitioner named below any information necessary to provide the best care and collaboration.
I hereby authorize you to release to any physician or practitioner or the practitioner named below any medical or other records or information necessary to provide the best care and collaboration. These records are to be utilized for the coordination of care.
Name of Practitioner
Acknowlegment for Client and Practitioner Safety
*
I agree to abide by any and all safety practices implemented by my therapist.
I have been informed of the precautions taken by my therapist to ensure a safe clean environment for my session. I have read the COVID-19 information found on this website. I realize I will be required to answer a series of questions before each session to ensure a safe session for myself and my therapists. I attest that my answers are truthful, trust my therapist to assess all the other clients for safety, and hold harmless my therapist in the event I contract COVID as a result of a session.
Financial Responsibility
*
I agree to the financial policy.
I agree and acknowledge that I am responsible for payment of any balance due upon completion of each session unless prior arrangements are made. I understand that emergencies do arise that can result in missing an appointment. Please notify your practitioner as soon as possible if you will miss an appointment. There is no penalty for an infrequent late cancellation or missed appointment. If I fail to cancel two consecutive appointments, I will be responsible for payment of the full fee for both missed appointments prior to rescheduling another appointment.
512-294-3274
info@holistichealingarts.net
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