Massage Therapy Client Health Intake Form

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Men's Sexual Health Intake Form
Name: ____________________________________________________
Date of Birth: _________________
Work/Cell Phone: _____________________________ E-mail:_______________________________________________
Occupation: __________________________________________________________________________________________
Emergency Contact: _______________________________________________Phone: ___________________________
Are you currently under a physicians care for an acute or chronic illness? Y __ N __
If yes, please explain: _________________________________________________________________________
Your health care provider: ____________________________________________________________________
Are you currently taking any prescribed medication or dietary supplements? Y __ N __
If yes, please list: ______________________________________________________________________________
What are you currently experiencing that you would like addressed? Please explain: ________________
_______________________________________________________________________________________________________
How long have you been experiencing these symptoms? ____________________________________________
______________________________________________________________________________________________
___________________________________________________________________
How did you hear about us?
Health Information
Please mark an (X) by all current conditions and (P) for all past
conditions
__ Diabetes
__ Abdominal /digestive problems
__ Pregnancy
__ Fatigue
__ Allergies
__ Rash/fungus
__ Headaches, migraine
__ Anxiety
__ Sinus problems
__ Arthritis/tendonitis
__ Hearing problems
__ Sleep difficulties
__ Asthma or a lung condition
__ Hernia
__ Spinal disorders
__ Athletes foot
__ High blood pressure
__ Sprain/strain
__ Blood clots
__ Jaw pain/TMJ pain
__ Tension/stress
__ Chronic pain
__ Low blood pressure
__ Vision problems
__ Circulatory/heart problems
__ Muscle/bone injuries
__Varicose veins
__ Constipation/diarrhea
__ Muscle/joint pain
__ Other __________________________
__ Depression
__ Numbness/tingling
Elaborate on noted areas above: _________________________________________________________________________________
___________________________________________________________________________________________________________________

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