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INTAKE FORM
First name
Phone
Are you Pregnant?
*
Yes
No
If Yes, how far along are you pregnant?
Are you on any medication(s)?
*
Yes
No
If yes, what type of medication(s)?
Last name
Email address
Any underlying medical conditions?
*
Yes
No
If yes, please specify:
Any allergies? Asthma or trouble with breathing?
*
Yes
No
If yes, please specify:
SUBJECTIVE
Intensity of pain:
1
2
3
4
5
6
7
8
9
10
When did the pain start?
Problem areas needed for massage therapy:
Sensation of Pain:
Dull
Sharp
Tender
Itching
Cramping
Throbbing
Tingling
Stiff
Cold
Burning
Aching
Sensitive
Radiating
Shooting
Pressure
Do you have any physical or other disabilities?
Yes
No
If yes, specify any special accomodations that are needed:
Was there a specific incident that caused this pain?
Motor vehicle accident
Slept wrong
Sports/exercise
Fall
Work related
Other
If answered other, please specify:
What makes your pain worse?
What makes your pain feel better?
Does this pain prevent you from participating in...
Work
Sports/exercise
Leisure activities
Sleep
Other
If answered other, please specify:
How often do you experience pain?
All day/night long
It comes and goes
Only during movement
Do you have any limited range of motion?
Yes
No
If answered yes, please specify:
Have you seen other practitioners about this issue?
I have not seen a practioner
Massage therapist
Chiropractor
Physical therapist
Physician
Other
If answered other, please specify:
Submit
Thank you for your submition!
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