Massage Therapy Patient Intake Form - Advanced Spinal Care printable pdf download

Massage Therapy Patient Intake

Today’s Date:______/______/_______

Name:____________________________________________ Age_______ Date Of Birth_____________________________

Local Address__________________________________ City___________________State____ Zip___________________

Out of Town Address____________________________ City___________________State____ Zip_________________

Marital Status_________ Sex_______ S.S.#__________________ Home Phone____________Cell. Phone____________

Email Address:_____________________________________________

Employer_________________ Occupation _______________ Address _________________________________________

Phone_____________ Spouse ________________________ Employer________________________________________

Emergency Contact_________________Phone____________Relationship______________________________________

How did you hear about our office?

Check an option below:

Yellow Pages

Drive By

Walk-In

Internet

Referral (Please tell us who) ___________________

Other: ____________________

Current complaint

Please list the reason you are here to see a Massage Therapist_________________________________________________

_________________________________________________________________________________________________

How long have you had these symptoms_________________are they

Improving

Worsening

About the same

How did the condition start___________________________________ Is it

Mild

Moderate

Severe

What makes it worse ____________________________ What makes it better____________________________________

Current Health

Are you currently under any doctor’s care for an illness or injury? If so, please list his/her name and

address_______________________________________ Nature of illness or injury________________________________

If you are currently taking any prescription or nonprescription medications, list them below

__________________________________________________________________________________________________

Please list any medications you are allergic to_______________________________________________________________

Please indicate your height and weight ___________________What is your usual blood pressure______/_______

Health History

List any operations, surgeries or medical procedures

Date______ Procedure__________________ Date_______ Procedure___________________

If you have ever had in the past or currently have any serious illnesses or injuries, please list

Date______ Condition___________________ Date_______ Condition___________________

Please list any significant family illnesses________________________________________________________________

Massage Therapy Patient Intake Form - Advanced Spinal Care