Clinical Health Intake Form 1 Personal Info2 Massage History3 Health History Personal InfoName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (Cell or best contact number)*Phone (Secondary contact - not required)Email* Occupation / EmployerPrimary Care ProviderPrimary Care Provider PhoneEmergency Contact* First Last Emergency Contact Phone* Massage History / Treatment InformationHave you ever received a professional massage?*YesNoDate of last massage What results do you want from your sessions?Please check any areas of your body where you prefer not to receive massage: Head Face Neck Arms Chest Abdomen Back Buttocks Legs Feet Other OtherAre you currently seeing a healthcare practitioner?*YesNoPlease describe:List stress Reduction and Exercise Activities. Please include frequency.List current Medications, Herbals & Supplements and reason for use. Please Include OTCs such as Aspirin, Ibuprofen, Claritin, etc. Previous HistorySurgeries (Include year and treatment received)Accidents (Include year and treatment received)Health HistoryMusculoskeletal Bone or Joint Disease Tendinitis / Bursitis Broken / Fractured Bones Arthritis / Gout Jaw Pain / TMD Lupus Sprains / Strains Low Back, Hip, Leg Pain Neck, Shoulder, Arm Pain Headaches, Head Injuries Spasms/Cramps Other OtherCirculatory Heart Condition Varicose Veins / Phlebitis Blood Clots High / Low Blood Pressure Lymphedema Thrombus / Embolism Other OtherRespiratory Breathing Difficulty / Asthma Emphysema Sinus Problems Allergies Other Specify AllergiesOtherNervous Herpes / Shingles Numbness / Tingling Pinched Nerve Other OtherReproductive Pregnant Ovarian / Menstrual Problems Prostate PMS Other If pregnant, Trimester:OtherSkin Allergies Rashes Athletes Foot Herpes / Cold Sores Warts Other Specify AllergiesOtherDigestive Constipation Gas / Bloating Diverticulitis Irritable Bowel Syndrome Ulcers Other OtherOther Cancer / Tumor Diabetes Chronic Fatigue Chronic Pain Eating Disorders Sleep Disorders Bladder / Kidney Ailment Drug / Alcohol Addiction Caffeine / Tobacco Addiction Migraines / Headaches Anxiety / Stress Syndrome Depression Contact Lenses Consent and Contract for CareIt is my choice to receive massage therapy or yoga, and I give my consent to receive treatment. I have completed this form to the best of my knowledge and will inform the massage therapist or yoga instructor or any changes in my physical health. I understand that massage therapist and yoga instructors can not diagnose illness, disease, or any other medical, mental, or emotional disorder. Nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I realize that the treatment is being given for the well being of my body, mind and spirit. This includes stress reduction, relief from muscular tension, spasm or pain, also for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my wellbeing is compromised. I acknowledge that massage and yoga are not substitutes for medical examinations or diagnosis; I am responsible for consulting a qualified physician for any physical ailments that I have. I understand that massage therapy and yoga is a therapeutic health aide and is non-sexual. Consent* By checking this box I agree to the above statement.