Therapy Intake Form And Client Agreement
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2Therapy Intake Form
Jolene Kelley, LMT #17693
407 NE 12
Avenue
th
Portland, Oregon 97232
503-319-9747 /
Today’s Date: _____________
Name: _ _____________________________________Phone: _ ____________________ D OB: _ ____________________
Address: _ ____________________________________ C ity: _ ______________ S tate: _ _________ Z ip: _ _____________
Email A ddress: _ ____________________________________Referred b y: _ _________________________ _ ___________
Emergency C ontact: _ __________________________ P hone: _ ____________________ R elationship: _ ______________
Please r eview t he f ollowing c onditions a nd c ircle: “ Y” i f i t a pplies t o y ou o r “ N” i f i t d oesn’t a pply t o y ou. I f y ou c ircle “ Y”
please d escribe a pplicable i nformation i n t he s pace p rovided b elow.
Y N
Do y ou f requently s uffer f rom s tress?
Y N
Do y ou h ave P MS?
Known c ause(s)? _ _______________________
Explain: _ ______________________________
Y N
Do y ou h ave d igestive i ssues?
Y N
Do y ou h ave v aricose v eins?
Explain: _ ______________________________
Where? _ ______________________________
Y N
Do y ou h ave d iabetes?
Y N
Do y ou h ave c ancer?
Explain: _ ______________________________
Explain: _ ______________________________
Y N
Do y ou h ave a ny a llergies?
Y N
Are y ou p regnant?
Explain: _ ______________________________
How f ar a long? _ ________________________
Y N
Do y ou e xperience f requent h eadaches?
Y N
Do y ou h ave c hronic p ain?
Known c ause? _ _________________________
Where? _ ______________________________
Y N
Do y ou h ave n umbness/tingling?
Y N
Are y ou t aking a ny m edications?
Where? _ ______________________________
What? _ _______________________________
Y N
Do y ou s uffer f rom a rthritis?
Y N
Do y ou s uffer f rom d epression?
Where? _ ______________________________
Explain: _ ______________________________
Y N
Do y ou h ave c hronic f atigue?
Y N
Do y ou h ave a ny e ating d isorders?
Explain: _ ______________________________
Explain: _ ______________________________
Y N
Do y ou h ave c ardiac o r c irculatory p roblems?
Y N
Do y ou h ave a ny c ommunicable d iseases?
Explain: _ ______________________________
Explain: _ ______________________________
Y N
Do y ou h ave h ormone i mbalances?
Other C onditions/Comments:
Explain: _ ______________________________
_____________________________________________
Y N
Do y ou s uffer f rom e pilepsy o r s eizures?
Explain: _ ______________________________
_____________________________________________
Please e xplain y our q uality o f s leep. H ow m any h ours o f s leep d o y ou a verage n ightly?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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