Massage Intake Forms - Maximized Health Chiropractic
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2Massage Intake Forms
Name __________________________________ □ Male □ Female
Date of Birth _______________
SECTION 1
Address ______________________________ City ______________State _______ Zip Code ______________
Home Phone ___________________ Cell Phone ____________________Email_________________________
In Case of Emergency, who should be notified?
Name ________________________________Relation _________________ Phone_____________________
Did someone refer you to our clinic? □ Yes □ No If yes, by whom? __________________________________
Are you currently seeking care from any other healthcare professional? □ Yes □ No
Please explain: ________________________________________________________________________
SECTION 2
(Medical Massage is often covered by insurance. Our insurance specialist can help verify any benefit you might have.)
Insurance Company Name______________________________________________ □ Private □ Group
Membership/Cert #___________________________Policy/Group #________________________________
SECTION 3
Occupation___________________________________ How long? __________
When was your last massage session?________ Desired pressure? □ light □ medium □ firm □ deep
What is your overall purpose for seeking Massage/Bodywork? (check all that apply)
General Relaxation
Injury Recovery
Stress Management
Pain Management
Injury Prevention
Other ___________________________________
Please tell us about your general health conditions: (check all that apply)
High/Low Blood Pressure
Chronic Headaches
Lung Conditions
Pregnancy (weeks______)
Migraines
Muscle Spasms
Diabetes
Arthritis/Bursitis
Joint pain/conditions
Recent Surgeries
Osteoporosis
Sinus Problems
Recent injuries
Numbness/tingling
Nerve Damage
Cancer
Insomnia
Medications (list below)
AIDS/HIV
Bladder/Kidney problems
Other conditions (list below)
List Explanations: ___________________________________________________________________________
__________________________________________________________________________________________
Please mark areas on image to the right of:
- Consistent Pain
- Nerve Damage
- Numbness/Tingling
- Recent Injuries
- Surgeries
- Areas to Avoid
7384 South Alton Way, Suite B Centennial, CO
Phone: 303.462.4476
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