Medical Massage Intake Medical Massage Step 1 of 7 14% 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 Date MM slash DD slash YYYY DOB MM slash DD slash YYYY Email 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 PhoneHow Did You Find Us? Occupation Height Weight Sex Male Female What are your goals for this visit? Add RemoveWhat are your health concerns? Add RemoveDo you currently exercise? Yes No 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? What past medical history have you had? Any family members with medical conditions? List any major surgeries, traumas, allergies List any medications you are on and whyMedicationReason Add RemoveList any herbs or supplements your taking Add Remove How many hours do you sleep?Please enter a number from 0 to 24.How many meals do you eat a day?Please enter a number from 0 to 24.When do you eat these meals? Do you eat alone or rushed? Alone Rushed 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? How much caffeine do you drink in a day? Do you drink alcohol or smoke? How often do you eat out? 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 you bowels? Are they hard to pass, normal or soft? Do you have hemorrhoids? Do they bother you? Do you experiance 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. 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 WEBSITESignature
