Goble Heal Chiropractic Massage Intake Form
ADVERTISEMENT
1
2For GHC Use: ( )GHCA ( )GHC INACTIVE ( )MASSAGE
Entered ____________
____________________
______________________
Last name
First name
Goble Heal Chiropractic Massage Intake
__________________
______________________ ___________________ ______________________
Home Phone
Cell Phone
Social Security #
Date of Birth
The following information will be used to help plan
work, sports or hobby?
Yes
No
safe and effective massage sessions. Please answer
If yes, describe____________________________
the questions to the best of your knowledge.
8. How has stress affected your health? Muscle
Date of Initial Visit_________________
tension( ) Anxiety( ) Insomnia( )
1. Have you had a professional massage before?
Irritability( )
Yes
No
other__________________________
If yes, how often do you receive massage therapy?
9. Is there a particular area of the body where you
________________________________________
are experiencing tension, stiffness, pain or other
2. Do you have any difficulty lying on your front,
discomfort?
Yes
No
back or side?
Yes
No
If yes, identify____________________________
If yes, explain_____________________________
10. Do you have any particular goals in mind for this
3. Do you have any allergies to oils, lotions or
massage session?
Yes
No
ointments?
Yes
No
If yes, explain_____________________________
If yes, explain_____________________________
Are you currently under medical supervision?
4. Do you have sensitive skin?
Yes
No
Yes No
5. Are you wearing contact lenses( )dentures ( )a
If yes, explain_____________________________
hearing aid( )?
11. Do you see a chiropractor? Yes No
6. Do you sit for long hours at a workstation,
If yes, how often?__________________________
computer, or driving?
Yes
No
12. Are you currently taking any medication?
Yes
No If yes,
7. Do you perform any repetitive movement in your
list______________________________________
List any specific areas you would like the massage therapist to concentrate on during the session:
Massage Therapist notes:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business