Clinical Health Intake Form 1Personal Info2Massage History3Health History Personal InfoName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (Cell or best contact number)*Phone (Secondary contact - not required)Email* Occupation / Employer Primary Care Provider Primary Care Provider PhoneEmergency Contact* First Last Emergency Contact Phone* Massage History / Treatment InformationHave you ever received a professional massage?* Yes No Date of last massage MM slash DD slash YYYY 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 Other Are you currently seeing a healthcare practitioner?* Yes No Please 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)COVID-19 Information1. Have you had a fever in the last 24 hours of 100°F or above?* Yes No 2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?* Yes No 3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?* Yes No 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 Other Circulatory Heart Condition Varicose Veins / Phlebitis Blood Clots High / Low Blood Pressure Lymphedema Thrombus / Embolism Other Other Respiratory Breathing Difficulty / Asthma Emphysema Sinus Problems Allergies Other Specify Allergies Other Nervous Herpes / Shingles Numbness / Tingling Pinched Nerve Other Other Reproductive Pregnant Ovarian / Menstrual Problems Prostate PMS Other If pregnant, Trimester: Other Skin Allergies Rashes Athletes Foot Herpes / Cold Sores Warts Other Specify Allergies Other Digestive Constipation Gas / Bloating Diverticulitis Irritable Bowel Syndrome Ulcers Other Other Other 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. I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By agreeing to this statement, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.Consent* By checking this box I agree to the above statement.