The Phoenix Institute of Massage & Bodywork
Your Future is NOW!

Wellness Intake History

 

Date: ___/ ___/____

 

How did you hear about us? ( ) Ad ( ) Healthcare Referral ( ) Friend/Family

Whom may we thank for the referral? _____________________________

 

Name: Last _____________________ First_________________________

DOB__ /__ /____   Age _____                                  Sex: ( ) Male ( ) Female

Address_____________________________________________________

City, State, Zip _______________________________________________

Telephone (     ) ____-_____Cellular (    ) ____-____ Other (    ) ___-____

Email Address________________________________________________

Allow Email/Text Messages by Phoenix Spa for Appointment Reminders Follow-ups and Special Discounts   ( ) Yes ( ) No

Emergency Contact Name & Number: _____________________________

Marital Status: __________________ Occupation:____________________

Physician & number: __________________________________________   Chiropractor & number: ________________________________________

Have you had Massage Therapy before? (  ) Yes  (  ) No

Was it helpful? (  ) Yes  (  ) No  

 

Main Complaint that you are seeking treatment?_____________________

When did this problem begin? ___________________________________ What caused this problem? _____________________________________

What diagnosis, if any, have you received for this problem?_____________

What treatments have you tried?__________________________________

What makes it better? _______________What makes it worse?_________

Surgeries & dates: ____________________________________________

Medications: __________________For what Condition:_______________

Allergies:_______________ (drug, chemical, environmental)___________

 

 

Medical History:

 Have you had any of these conditions now or in the past?

Please check all that apply.

 ( ) AIDS/HIV ( ) Alcoholism ( ) Allergies ( ) Asthma

( ) Arthritis ( ) Anemia ( ) Cancer ( ) Diabetes Type 1 or 2

( ) Drug Addictions ( ) Depression ( ) Digestive Disorders ( ) Emphysema

( ) Fibromyalgia ( ) Herpes ( ) Hepatitis A/ B / C ( ) Heart Disease

( ) High Blood Pressure ( ) High Cholesterol ( ) Joint Replacements

( ) Lyme’s Disease ( ) Multiple Sclerosis ( ) Pacemaker ( ) Seizures

( ) Seasonal Allergies ( ) Sinus Infections ( ) Tuberculosis ( ) Other

 

Personal History: Circle yes/no where indicated

 Height ____Feet ___Inches   Weight Now ____Weight 1 year ago ___  Max Weight _____When?______

Do you smoke?   Yes    No     What? ____________

How much per day? ___________For how long?_________

Do you exercise regularly?  Yes   No

If so, how often & what type?__________________________________

Do you drink Coffee?   Yes   No           How much? ________________  

Do you drink Cola?   Yes    No             How much? ________________

Tea?    Yes      No         How much? _______ What Kind  ___________

Water?  Yes      No        How much? _______

Alcoholic Drinks?   Yes    No     Type? ________How much___________

 

Emotions/Stress/Sleep:

Do you experience any of the following? Check all that apply.

( ) Panic Attacks ( ) Depression ( ) Anxiety ( ) Anger / Short temper

( ) Poor Memory ( ) Difficult Concentration ( ) Fatigue ( ) Boredom

How do you relax or relieve stress?______________________________

How many hours do you sleep a night? ___________________________

How long does it take you to go to sleep? ________Dreams? Y/ N

Do you wake up at night?  Yes   No How many times do you wake up?___

Do you know what wakes you up?_______________________________

Are you able to go right back to sleep?  Yes   No     

If not, how long does it take to fall back to sleep?_____________________

 

Gastrointestinal:

I have or have had: check all that apply.

( ) Belching ( ) Acid Reflux ( ) Heartburn ( ) Gas ( ) Hernia

( ) Nausea ( ) Vomiting ( ) Vomiting Blood ( ) Stomach Pain ( ) Ulcers

Bowel Movements: How often?_____ Times per day OR times per week

Bowel Movement Qualities: check all that apply

( ) Burning sensation ( ) Irregular ( ) Constipation ( ) Diarrhea ( ) Gas

( ) Hemorrhoids ( ) Undigested Foods ( ) Hard/Dry Stool ( ) Painful Bowel Movements

 

Urinary:

Urination: How often?____ times per day

Color: ( ) Clear ( ) Yellow ( ) Dark yellow/orange

I have or have had: check all that apply

( ) Trouble starting stream ( ) Stop & Go Stream ( ) Frequent Urination

( ) Incontinence ( ) Pain ( ) Burning ( ) Blood in Urine ( ) Kidney Stones

( ) Dribbling with sneezing/cough ( ) Urinary Tract Infections

 

Women:

Age at start of Menses: ____Number of Days of Cycle Days of Bleeding___

Date of last Menses:__/__/___Date Menopause or Hysterectomy__/__/___

Describe your flow as: Light / Medium / Heavy

Color of Blood: Pale / Red / Dark Red Clots:

Do you experience emotional changes before or during your periods? Y/N

Do you experience cramping/discomfort before or during your periods? Y/N

Any vaginal discharge? Y/N Color Y/N  Itchy/Burning Y/N

Number of Pregnancies ___Miscarriages____ Hormones/Birth Control Y/N

 

Men:

I have or have had: check all that apply

( ) Prostatitis ( ) Impotence ( ) Blood or Mucous Discharge ( ) Other:

 

Eyes, Ears, Nose, Throat & Head:

I have or have had: check all that apply

( ) Frequent colds ( ) Frequent Sore Throat ( ) Chronic cough ( ) Cold Sores ( ) Coughing up blood ( ) Difficult inhaling ( ) Asthma ( ) Dizziness

( ) Nose bleeds ( ) Painful/Red eyes ( ) Coughing up Mucous ( ) Dry Mouth

( ) See Spots/Floaters ( ) Bleeding gums ( ) Shortness of Breath

( ) Ringing in the ears ( ) Frequent Headaches/Migraines 

 

Pain:

Please circle areas of pain or discomfort.

 Notes:______________________________________________________________________________________________________________________________________________________________________________

Cardiovascular:

I have or have had: check all that apply

( ) Chest Pain ( ) Palpitations ( ) Varicose Veins ( ) Phlebitis

( ) Cold Hands & Feet ( ) Irregular Heartbeat ( ) Poor Circulation ( ) Other:

Skin & Hair:

I have or have had: check all that apply

( ) Dry Skin ( ) Skin Rashes ( ) Eczema ( ) Psoriasis

( ) Acne ( ) Hives ( ) Hair loss ( ) Premature Graying

 

 

 

Miscellaneous:

Please let us know if there is any additional information that may help us serve you better. ______________________________________________

______________________________________________

 

 

 

 

To the best of my knowledge, the above information is complete and correct. I understand that reporting incomplete or inaccurate information can be dangerous to my health. I understand that I am solely responsible for any errors or omissions that I may have made in the completion of this form. I understand that it is my responsibility to inform my health care provider if I ever have a change in health. I understand that massage therapy services are for the primary purpose of short-term relaxation and the relief of muscular tension. I understand that massage therapy services are in no way a substitute for examination, diagnosis or treatment by a physician. I understand that individuals providing massage therapy services are not qualified to diagnose, prescribe or treat any physical or mental illness and are not qualified to perform spinal or skeletal adjustments. I acknowledge that any information I receive from individuals performing massage therapy services is educational in nature and is to be used at my own discretion.

 

 

___________________________________________________________

Signature of Patient, Parent, Guardian or Personal Representative               Date

 

___________________________________________________________

Please print name of Patient, Parent, Guardian or Personal Representative    Date

 

___________________

Relationship to Patient

 

 

Thank you for helping us to better help you in your quest for health!

Associated Bodywork & Massage Professionals
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