CLIENT INTAKE FORM
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Personal Info
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Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
Health Questions
Asthma
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Meniere Disease
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Concussion
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Mood Disorder
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Congenital Heart Defect
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Pacemaker
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Depression
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Past Heart Surgery
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Epilepsy
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Schizophrenia
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Hearing Impairment
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Stroke
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Heart Attack
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Vertigo
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Heart Condition
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Infectious
Pneumonia
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Strep
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Lyme Disease
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Treatment Goals
Health Advice for Healing
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Stress Relief
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Support in Healing/Recovery
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Other
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
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Willing to wash hands before leaving clinic
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Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you been tested for COVID?
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Have you had the antibody test?
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Fever Over 100.4 degrees
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Fever Over 38 degrees
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Headaches
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New Onset of Cough
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Worsening Chronic Cough
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Sore Throat
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Difficulty Swallowing
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Shortness of Breath
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Difficulty Breathing
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Have you had a new onset of muscle aches and pain since the emergence of the virus?
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Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
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Fatigue
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Chills
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Pink eye (conjunctivitis)
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Nasal or sinus congestion
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Runny nose/nasal congestion without other known cause
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Nausea
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Vomiting
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Diarrhea
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Abdominal Pain
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Sudden onset body aches
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New rash or other skin changes
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Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
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Regular cardio exercise
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Can you exercise to get your heart rate up without any problem?
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Can you exercise to get your respiratory rate up without any problem?
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Contact with someone with COVID
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Contact with someone who was in contact with COVID
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Contact with anyone with acute respiratory Illness
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Recent domestic air travel
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Recent international air travel
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Recent travel to area with high infection rates
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Recent travel outside your province within the past 14 days
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Been in group where social distancing not observed
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Are you considered high risk?
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Spend time around anyone that is high risk
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If over 70, unexplained or increase number of falls?
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If over 70, acute functional decline?
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If over 70, worsening of chronic conditions?
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If over 70, symptoms of delirium?
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Tension
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Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Rebound
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Sinus
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Other Headaches
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Respiratory
COPD
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Tuberculosis
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Cystic Fibrosis
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Emphysema
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Infectious Respiratory Conditions
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Respiratory Conditions
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Respiratory Tract Infection
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Asthma
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Shortness of Breath
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Bronchitis
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Chronic Cough
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Sinus Problem
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Other Respiratory
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Musculoskeletal
Baker's Cyst
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Spasms / Cramps
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Degenerative Disk Disease
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Jaw Pain (TMJD)
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Osteoporosis
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Paget Disease
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Bone Disease
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Spondylolisthesis
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Dislocation
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Joint Injury
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Plantar Fasciitis
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Bone or Joint Disease
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Strain/Sprain
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Psoriatic Arthritis
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Broken Bone / Fracture
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Temporomandibular Joint Dysfunction
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Ehlers-Danlos Syndrome
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Muscular Dystrophy
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Adhesive Capsulitis
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Recti Diastasis
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Fibromyalgia
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Myasthenia Gravis
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Amyotrophic Lateral Sclerosis (ALS)
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Ankylosing Spondylitis
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Scleroderma
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Chronic Fatigue Syndrome
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Torticollis
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Fracture
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Osgood-Schlatter Disease
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Arthritis
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Scoliosis
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Chronic Myofascial Pain Syndrome
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Whiplash
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Gout
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Osteoarthritis
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Artificial Joints / Special Equipment
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Sinus Problems
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Compartment Syndrome
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Hereditary/Congenital Deformity
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Osteomalacia
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Other Musculoskeletal
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Blood
Thrombosis/Embolism
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Anemia
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Bleeding Disorder
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Blood Thinner Medication
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Fainting Spells
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Hepatitis
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HIV/AIDS
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Other Blood
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Neurological
Post Polio Syndrome
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Syringomyelia
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Bell's Palsy
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Cerebral-vascular Accident
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Fibromyalgia
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Sciatic Pain
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Tethered Cord
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Brain Disorder
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Cerebrospinal Fluid Leak
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Herniated Disc
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Seizure Disorder
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Tingling
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Brain Injury
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Chiari Malformation
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Huntington Disease
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Loss of Sensation
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Shingles
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Transient Ischemic Attacks (TIA)
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Burning
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Chronic Pain Disorder
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Multiple Sclerosis
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Shingles / Herpes
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Twitching of Face
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Carpal Tunnel
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Dizziness
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Numbness
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Sleeping Disorders
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Vertebral and Spinal Cord Injury
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Cerebral Palsy
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Dural Ectasia
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Parkinsons
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Stabbing
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Cerebral Vascular Accident (Stroke)
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Epilepsy
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Peripheral Neuropathy
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Stroke
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Fatigue
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Other Neurological
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Family History
Cancer
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Cardiovascular
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Diabetes
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Respiratory
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Arthritis
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Cardiovascular
Congenital Heart Defect
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Myocardial infarction
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Congestive Heart Failure
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Pacemaker
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Aneurysm
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Coronary Artery Disease
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Pericarditis
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Angina
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Heart Attack
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Peripheral Vascular Disease
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Atherosclerosis
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Heart Disease
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Phlebitis
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Blood Clots
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High Blood Pressure
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Stroke
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Cardiac Arrhythmia
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Low Blood Pressure
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Swelling
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Chest Pain
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Lymphedema
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Varicose Veins
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Other Cardiovascular
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Gastrointestinal
Diarrhea
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Digestive Conditions
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Diverticulitis
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Acid Reflux
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Celiac Disease
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Constipation
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Crohn's Disease
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Skin
Plantar's Wart
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Psoriasis
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Acne
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Rash
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Allergic Dermatosis
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Rosacea
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Alopecia
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Athlete's Foot
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Eczema
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Infectious Skin Conditions
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Sensitive Skin
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Other Skin
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Reproductive
Gynaecological Conditions
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Menopause
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Pregnancy
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Premenstrual Syndrome
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Endometriosis
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Other Reproductive
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Endocrine
Acute Pancreatitis
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Adrenal Fatigue
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Diabetes
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Hyperthyroidism
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Hypothyroidism
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Other Endocrine
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General Injury Related Questions
Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Miscellaneous
Visually Impaired
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Hearing Impaired
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Weakened Immune Function
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Insomnia
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Liver Disease
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Loss of Balance
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Mental Health Issues
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Music Preference
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Surgical Pins or Wire
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ADHD
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Vision Problems
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Autism
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
Due Date
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Trimester
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Weeks Pregnant
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Nausea
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Problems with Placenta
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Sciatica
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Separation of Rectus Muscle (diastasis recti)
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Separation of Symphysis Pubis
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Carpal Tunnel Syndrome
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Hypoglycemia
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Massage Goals
Injury Rehabilitation
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Positive Reinforcement
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Strength Training
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Address Health Issues
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Stress Relief
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Alternative Therapy
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Balance
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Flexibility
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Improve Fitness
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Increase Well-Being
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Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Other
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Medium Pressure Preferred
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Deep Pressure Preferred
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
Characters:
0
/255
Immobilization Did it help?
Characters:
0
/255
Other creams, gels or unguents
Characters:
0
/255
Other therapies
Characters:
0
/255
Physical Activities You Participate In
Marathon
Characters:
0
/255
Triathlon
Characters:
0
/255
Pilates
Characters:
0
/255
Waterpolo
Characters:
0
/255
Rugby
Characters:
0
/255
Weight Lifting
Characters:
0
/255
Running
Characters:
0
/255
Yoga
Characters:
0
/255
Baseball
Characters:
0
/255
Soccer
Characters:
0
/255
Crossfit
Characters:
0
/255
Softball
Characters:
0
/255
Football
Characters:
0
/255
Swimming
Characters:
0
/255
Golf
Characters:
0
/255
Lacrosse
Characters:
0
/255
Tennis
Characters:
0
/255
Other Activities
Characters:
0
/255
Number of Times of Week You Practice
Once a week
Characters:
0
/255
2-4 times a week
Characters:
0
/255
More than 4 times a week
Characters:
0
/255
Less than a couple of times a month
Characters:
0
/255
Allergy
Miscellaneous
Characters:
0
/255
Environmental
Characters:
0
/255
Food
Characters:
0
/255
Latex
Characters:
0
/255
Medical
Characters:
0
/255
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