moonshadow.massagetherapy.com Intake For… · Web viewThe practitioner does not diagnose medical...
Transcript of moonshadow.massagetherapy.com Intake For… · Web viewThe practitioner does not diagnose medical...
Confidential Intake FormPractitioner: DO NOT send this page with your case study report – for
your records ONLY
Please email this form to [email protected]
Name: ____________________________ Date of Initial Visit _________________
Address ___________________________________________________
State ___________ Zip ____________________
Phone______________________________
email_________________________________
Date of Birth ____________________ Age __________
Female _____ Male_____ Other________
Preferred Pronoun _______________
Occupation ___________________________________________
Marital/Relationship status __________________________________
Referred by _________________________________________
Revised November 2018
Client Confidentiality and Release FormI understand this modality is not a replacement for medical care. The practi-tioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuti-cals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend re-ferral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.
Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance. HIPAA regula-tions require all practitioners obtain a signed release form from their client before taking any information about them. The best way to be fully compli-ant is to obtain this release signature at the initial consultation. Clients should receive a copy of the form they signed (upon request), and the practi-tioner maintains a copy for their records
I, (name) ____________________________________________
give my permission, for my practitioner, to take notes including health his-tory/ medical and /or personal information I choose to disclose to him/her. I understand this information may be used for the purpose of practitioner cer-tification and/or may be shared with the Arvigo Institute, LLC for statistical data collection only. All relevant identifying information will not be disclosed, such as name, address, social security number, date of birth.
Client Signature: ______________________________________ Date: ______________
Practitioner signature ____________________________________________ Date: ___________________
Revised November 2018
Reason For Visit
Primary reason for visit:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
When did your first notice it? ___________________________________________________
What brought it on? _____________________________________________________
Describe any stressors occurring at the time _____________________________________
____________________________________________________________________________
____________________________________________________________________________
What activities provide relief? __________________________________________________
What makes it worse? ___________________________________________________
Is this condition getting worse? ___________________
interfere with work ______. sleep ______ recreation _______
Have you had massage/bodywork before? ______________
What type? ___________________________________
Revised November 2018
For Administrative Use OnlyClient Initials: _________Case Study #_________Age_________ Anatomy: Male ________ Female_________ Date of Visit: __________________ Practitioner Name _____________________________________________
Medical History
Are you currently under the care of another health care provider(s)? _________________
Reason(s) ___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Name(s) of Practitioner ________________________________________________________
Address ____________________________________________________________________
Phone ______________________ Email __________________________________________
Current Medications and /or Supplements/Remedies: ______________________________
____________________________________________________________________________
____________________________________________________________________________
Allergies: specify allergen and reaction: _________________________________________
____________________________________________________________________________
Surgical History (year and type) and/or Recent Procedures: _________________________
____________________________________________________________________________
____________________________________________________________________________
Hospitalizations: _____________________________________________________________
____________________________________________________________________________
Accidents or Traumas_________________________________________________________
____________________________________________________________________________
Falls/Injuries to Sacrum/head/tailbone (describe) __________________________________
____________________________________________________________________________
____________________________________________________________________________
Revised November 2018
Other: Please review and check the following:
Other (not mentioned above):
Family HistoryStill Liv-ing?
Cause of Death/age of Major Health Issues
Mother
Father
Siblings
Revised November 2018
HeadachesType:
Past Present
Numbness in feet or legs when standing
Past Present
Asthma Sore heels when walking
Cold Hands or feet
Anxiety
Swollen ankles Depression
Sinus ConditionsFrequent Colds
Sleep Disturbance
Seizures Fainting Spells
Low Back Pain Muscular Tension:Location:
Skin Disorders:Type
Varicose VeinsHemorrhoidsLocation
Sciatica Herniated/Bulging Discs
Painful/SwollenJoints
Artificial/Missing limbs
High or Low BloodPressure
Contact Lenses
Dentures/Partials Cancer (past or current)Type
Maternal Grandmother
MaternalGrandfather
Paternal Grandfather
Paternal Grandmother
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Digestion and Elimination
Typical Breakfast: ____________________________________________________________
Typical Lunch: _______________________________________________________________
Typical Dinner: ______________________________________________________________
Snacks: _____________________________________________________________________
Water Intake (glasses/day) ___________________ Caffeine ____________________
Revised November 2018
Do you use Tobacco? ______ Quantity_____/ppd
Alcohol? ______ Quantity ______ounces/day
Marijuana? _______ Quantity ______
Other: _______________
Have you been under treatment for substance use?
What is the worst item in your diet ______________
What foods are your weakness__________________________
Are you subject to binge eating? _________________________
What foods_________________________________
Do you experience bloating/gas/burps after eating? _____________
What foods trigger this? __________________
How often are your bowel movements? ___________________________
Do your stools: sink ______ float _______
Constipation? _______ Blood in stool? ______
Mucus in stool? ________Pain when stooling? _______
Other concerns: ____________________________________________________________________________
____________________________________________________________________________
EMOTIONAL & SPIRITUAL
What is your opinion of yourself? _______________________________________________
____________________________________________________________________________
If possible, please describe the most negative emotion you experience _______________
____________________________________________________________________________
When do you most often feel this emotion: _______________________________________
Where are you? ________________________________________________________
Do you pray to or have a spiritual practice ________________________________________Revised November 2018
On a scale of 1 – 10 (1 being the lesser, 10 the greater) Please rate yourself:
Faith ________ Hope ________ Charity ________ Generosity ________
Sense of Humor ________ Sense of Fun ________ Fear ________ Grief ________
Other (describe briefly) ___________________________________________________
What are hobbies/ activities that provide you with a sense of pleasure and accomplish-ment?
____________________________________________________________________________
Describe your exercise routine (type, frequency) __________________________________
____________________________________________________________________________
What changes would you like to achieve in 6 months: ______________________________
____________________________________________________________________________
One Year: ___________________________________________________________________
____________________________________________________________________________
Method of Contraception (circle)
pills patch diaphragm injection condoms IUD abstinence rhythm method
Fertility Awareness Other _____________
Length of time using method _________________________________Page 4
Last Pap smear ___________ Results (if known) __________________________________
Are you under the treatment for Infertility _____________
Describe current treatment to date: _____________________________________________
____________________________________________________________________________
(IUI, IVF, etc.) ________________________________________________________________
Revised November 2018
Gynecological Provider: _______________________________________________________
Address ___________________________________________ Phone ___________________
Menstrual History Review and check as indicated:
Age of Menses: __________ What was this like for you? ___________________________
Last Menstrual Period: ____________ Length of Menses_______________
Are you trying to conceive? ___________ Possibility of Pregnancy _______________
Painful Periods Past Present Irregular cyclesEarly Late
Past Present
Heaviness in Pelvis prior to menses
Dark Thick Blood at:BeginningEnd Both
Excessive BleedingPads per Hour
Headache or Migrainewith menses
Dizziness Bloating
Water Retention Ovulation:Painful
Revised November 2018
Reproductive Health History - Female Anatomy
Failure to
EndometriosisLocation (if known)
FibroidsLocation (if known)
Uterine or CervicalPolyps
Uterine Infection(s)
Vaginal Infection(s) CystsLocation:
Bladder Infection(s) Urinary Incontinence
Painful Intercourse Vaginal Dryness
Episodes of Amen-orrhea
How long?
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Pregnancy History:
Number of Pregnancies:
Number of Births:Dates:
Complications: Miscarriages: Terminations:
Premature Births: Spotting during Pregnancy
Weak Newborns at Birth
Incompetent Cervix
Revised November 2018
Briefly describe your experience with:
Pregnancy: __________________________________________________________________
____________________________________________________________________________
Labor: ______________________________________________________________________
____________________________________________________________________________
Birthing _____________________________________________________________________
____________________________________________________________________________
Post-Partum: ________________________________________________________________
____________________________________________________________________________
Maternal Family History of (please circle)
Infertility Fibroids Endometriosis PMS Menopause
Cancer (type) _____________. Menstrual Problems ______________
Other_________________________________
Medications your mother took when she was pregnant with you (if any)
____________________________________________________________________________
Your Birth Trauma (if known) ___________________________________________________
____________________________________________________________________________
Other:
Rate your interest in Sex:
High_________Moderate__________Low______________None__________
Revised November 2018
Do you have or ever had difficulty experiencing orgasms __________________________
Do you have a history of rape _______ trauma _______ incest _______
If so,-when_____________________________________________________________
Did you undergo counseling for this? ______________________________________
What was this like for you ________________________________________________
Please feel free to share any additional information:
Revised November 2018
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Menopause
Age symptoms began: ____________
Are they getting worse __________ better ________________ same ___________
Are you on/ or ever been on hormone replacement therapy? ______
if so, how long__________________________
Name and dose_________________________________________________________
Reason for stopping_____________________________________________________
Age of Mother at menopause: ________
Concerns/Experience____________________________________________________
Check the following symptoms that apply to you:
Hot flashes Insomnia Fatigue Memory Loss Mood Swings
Vaginal Dis-charge
Dry Vagina Depression Anxiety Irritability
Spotting Flooding Irregular Menses
Painful Inter-course
Increased Libido
Decreased Li-bido
Disturbed Sleep Pattern
Additional Information:
Revised November 2018
Reproductive Health History - Male Anatomy
Please check the symptoms below that apply
Painful Urination Past Present
Urinary Retention Past Present
Urinary Inconti-nence orDribbling
Difficult starting or holding urine stream
Weak or InterruptedUrine flow
Blood or pus in urine
Pain or Burning withUrination
Pelvic pressure
Nocturnal UrinationHow many times?
Insatiable sex drive
Pain in lower back, esp. after intercourse
Pain or DiscomfortBetween scrotum and testicles
Pain or Discomfort in:PenisTesticlesRectum
Pain or Discomfort in inner thighs:LeftRightBoth
Frequent Bladder orKidney InfectionsWhen?
Erection:Difficulty in Obtain-ingMaintainingPainful ejaculation
Results of PSA (prostate specific antigen) Test if known_________ Date done__________
Results of Sperm count (if applicable and known) ______________ Date done__________
Family History of Prostate Disease: Yes _____ No _____ Type _________________
Relationship _______________________________
Family History of Cancer: Yes _____ No _____ Type _________________
Relationship_______________________________
Sexually transmitted: Yes _____ No _____ Type if Known__________________________
Revised November 2018
Rate your interest in Sex: High ______ Moderate _______ Low ________ None _______
Do you have a history of rape _______ trauma _______ incest ________
If so, when? ____________________________
Did you undergo counseling for this? ___________________________________________ What was this like for you _____________________________________________________
Additional Information you feel important your practitioner should know that is not mentioned here:
Revised November 2018