Massage Intake - Patient Information Form Page 2

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Massage Intake
Basic Information
Name ___________________________________
__________Date________________
Address___________________________________________________________________________
City ___________________________________ State _____________ Zipcode ______________
Telephone # (home)______________________ (work) ________________________
(cell)________________________ Is it ok to leave a message?_____
Email Address ____________________________Age _______ Date of Birth _________
Gender _______
Occupation _______________________
How did you hear about our clinic?_____________________________________________________
Emergency Contact____________________________Relationship_______Phone _______________
History
Have you ever received a professional massage? Y N Date of last massage___________________
What results do you want from your massage sessions?____________________________________
List any exercise activities and frequency________________________________________________
_________________________________________________________________________________
Are you currently under the care of a medical professional?
Y N
If yes, where from and whom?________________________________________________________
List any current medications and purpose_______________________________________________
_________________________________________________________________________________
List any injuries/accidents/illnesses still affecting you______________________________________
_________________________________________________________________________________
List any surgeries and date___________________________________________________________
Please mark any of the following that you now have or have had.
Musculoskeletal
Circulatory
Respiratory
Bone or joint disease
Heart Condition
Breathing difficulty
Tendonitis/Bursitis
Phlebitis/Varicose Veins
Emphysema
Arthritis/Gout
Blood Clots
Allergies _________
Lupus
High/Low Blood Pressure
Sinus Problems
Spinal Problems
Thrombosis/Embolism
Other___________
Other_____________
Other_____________
PATIENT NAME:__________________________________________________________
PATIENT DOB:____________________________
KWAN-YIN HEALING ARTS CENTER
2330 NW FLANDERS ST. SUITE 101
PORTLAND, OR 97210
PH: 503.701.8766
FAX: 503.241.5484

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