Intake Forms Medical Intake (1) Step 1 of 14 7% BY COMPLETING THIS FORM, WE WILL BE ABLE TO FOCUS ON THE AREAS OF MOST BENEFIT TO YOU. WE ARE HERE AS A RESOURCE TO GIVE SUGGESTIONS, IDEAS AND OFFER SERVICES. IT IS OUR DESIRE TO EMPOWER YOU TO LIVE THE HEALTHIEST LIFE POSSIBLE. THIS WILL TAKE EFFORT, TIME, AND THE WILLINGNESS TO MAKE THE CHANGES NECESSARY. WE BELIEVE THE BODY AND THE MIND HAVE THE POWER AND ENERGY TO CREATE NEW LIFE WITHIN YOU!Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneWork PhoneBest Time and place to reach you? Whom may we thank for referring you or how did you find us? What are your goals for this visit? Sex Male Female DOB MM slash DD slash YYYY AgeHeight Weight Marital Status Single Married Widowed Separated Divorced Occupation Employer Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer Phone Spouse's Name First Last Spouse's Date MM slash DD slash YYYY Spouse's Occupation Spouse's Employer In case of Emergency, Contact First Last Relationship Home PhoneWork Phone Is condition due to an accident? Yes No Date MM slash DD slash YYYY Type of accident Auto Work Home Other Who Whom have you made a report of your accident? Auto Insurance Employer Workers Comp Other Attorney Name (if applicable) When did your symptoms appear? MM slash DD slash YYYY What treatment have you already received for your condition? Medication Surgery Physical Therapy Chiropractic Care None Other Other Type of pain? Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Cramps Stiffness Swelling Other How often do you have this pain? Is it constant or does it come and go? Does is interfere with Work Sleep Daily Routine Recreation Activities or movements that are painful to perform Sitting Standing Walking Bending Lying Down Name and address of doctor(s) or other healthcare practioner(s) who have treated you for your conditionInclude address and phone Have you ever received a professional massage? Yes No Why did you come for our service? Relaxation Pain Therapy Other Other What results would you like to achieve? What are your health concerns? Prioritize the areas of your body that you wish to be massaged. Please note any areas of your body that you prefer not to be massaged Please check conditions or symptoms you currently have or have had in the past Anemia Anorexia Appendicitis Arthritis Asthma Blood clots Breathing difficulty Bursitis Bronchitis Bulimia Cancer Chemical dependency Diabetes Emphysema ED or Prostate Issues Epilepsy Fractures Glaucoma Head Injuries Heart disease Hepatitis Hernia Herniated disk Herpes High blood pressure Jaw pain/TMJ But the team a Lymphedema Mononucleosis Multiple sclerosis Osteoporosis Pacemaker Parkinson’s disease Pinched nerve Pneumonia Polio Prolapsed Vaginal Tissue or Muscle Prosthesis Psychiatric care Rheumatoid arthritis Rheumatic fever Sinus problems Stroke Tendinitis Thyroid problems Tuberculosis Tumors or growths Ulcers Urinary Leakage Varicose veins Whiplash Other Other ListMedicationTaking For Add RemoveAllergies Add RemoveVitamins/Herb/Minerals Add RemoveExercise None Daily Moderate Heavy Work Activity Sitting Standing Light Labor Heavy Labor Lifestyle Smoking Alcohol Coffee/Caffeine High Stress Level Smoking Packs/DayDrinks/WeekCups/DayReason for stress Do you have major stress in your life? Yes No How do you relax? What was your relationship with your parents like when growing up? What is your water intake? Any family members with medical conditions? List any major surgeries, traumas or allergies How many hours do you sleep? How many meals do you eat a day? When do you eat these meals? Do you eat alone or rushed? Alone Rushed Are you on a special diet? How much caffeine do you drink in a day? Do you drink alcohol or smoke? How often do you eat out? How many servings of veggies do you eat in a day? How many servings of fruit do you eat in a day? Are you on a special diet? Please list what you ate in the past 24 hours and drank: Add Remove THE ELIMINATION CHANNELS OF YOUR BODY ARE KEY TO YOUR HEALTH. PLEASE ANSWER THE FOLLOWING QUESTIONS AS BEST AS YOU CAN. WE TALK ABOUT BOWELS QUITE A BIT HERE!How often do you move your bowels? Are they hard to pass, normal or soft? Do you have hemorrhoids? Do they bother you? Do you experience bad breath? Do you use lotions on your skin? What hair and skin products do you use? PLEASE ALSO LIST ANY HESITATIONS YOU MAY BE HAVING, AS WE WANT YOU TO FEEL COMFORTABLE IN SHARING WITH US. WE APPRECIATE YOUR HONESTY AND YOUR WILLINGNESS TO TRUST US IN HELPING YOU. WISH TO SHARE YOUR THOUGHTS? REMEMBER 90% OF OUR DISEASES AND DISORDERS COME FROM OUR EMOTIONAL UNBALANCES. WE DO OFFER TREATMENTS AND EDUCATION ON CORRECTING THESE UNBALANCES AND CORRECT THEM ON A DAILY BASE. Are you pregnant? Yes No Expected Due Date MM slash DD slash YYYY Please list any medical conditions, surgeries, accidents, bone, join or muscle diseases or injuries not specified aboveConditionDate Add Remove Consent I agree to the policy.WE ARE NOT DOCTORS, WE DON’T PRESCRIBE MEDICATIONS, WE DON’T ACCEPT INSURANCE, WE DO NOT INTEND TO DIAGNOSE, TREAT, PREVENT OR CURE ANY DISEASE. IF YOU ARE MAKING LIFESTYLE CHANGES, HAS MEDICAL NEEDS, IS TAKING PRESCRIPTION DRUGS, PREGNANT, THEY SHOULD SEEK THE ADVICE AND SUPPORT OF THEIR MEDICAL PHYSICIAN PRIOR TO EMBARKING ON A NEW LIFESTYLE PROGRAM. FOLLOWING OUR ADVICE, HEALTH PROGRAM OR THERAPIES IS A PERSONAL CHOICE. BY SIGNING THIS FORM, YOU INDICATE THAT YOU VOLUNTARILY ACCEPT TO UNDERTAKE THIS HEALTH PROGRAM AND YOU RELEASE ALLEN T. STANLEY, PRACTITIONER AND ALL TEAM MEMBERS FROM ANY AND ALL COMPLICATIONS THAT MAY ARISE FROM ANY OF THE SUGGESTED OR OFFERED THERAPIES, INCLUDING BUT NOT LIMITED TO RED LIGHT THERAPY, AO SCAN, TERAHERTZ, SOMATIC, MEDICAL MASSAGE, ULTRASOUND, MPS ACUPUNCTURE, THETA CHAMBER, RAIN ION CHAIR, ZIP SYSTEM, AO INFINITY WAND, RF FOOT DETOX AND ESSENTIAL OILS. RESPONSIBILITY AND LIABILITY FOR MAKING ANY CHANGES IN YOUR DIET, EXERCISE PROGRAM ARE YOUR SOLE RESPONSIBILITY AND YOUR RIGHT.Consent I agree to the policy.PLUS, WHEN YOU PREPAYMENT FOR AO SCANS OR DISCOUNTED BUNDLE PACKAGES ON ANY EQUIPMENT, THERE IS NO REFUNDS OF ANY KIND. YOU MAY GIFT THEM TO OTHERS AND ONLY GOOD FOR 12 MOS.Consent I agree to the policy.MUST PREPAID FOR ALL AO SCANS OR CONSULTATIONS, THROUGH WEBSITEConsent(Required) I agree to the privacy policy.I certify that the above information is correct to the best of my knowledge. I will not hold my massage therapist or any members of his or her staff responsible for any errors or omissions that I may have made in the completion of this form. I have disclosed all medical conditions that I am aware of and will inform my massage therapist of any changes in my health status. I hereby request the aforementioned health care providers release to you a report of my diagnosis treatment prognosis and recommendations and other information pertinent to your treatment of me. I understand that massage therapy services are designed to BA health aide and are in no way a substitute for a doctor’s care. Information exchanged during massage sessions is educational in nature and is to be used at my own discretion. Signature(Required)
