Benevolent Care and Touch Intake form

Client Intake Form:

This form can be filled out anytime before first meeting by going to https://intake.benevolentcnt.com

All information is held strictest confidence. At no given point is information disclosed or shared without your written consent. All essential fields are marked with a red asterisk. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose. Please put N/A for any question marked with an asterisk which doesn't relate to you.
Full Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
the date you complete this form
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Birth Date

MonthDayYear
Phone Number*
This is my:*
(type of phone)
E-mail*
example@example.com
Emergency Contact*
Emergency Contact Phone Number*
Your Occupation
Do You Take Any Medication? *
Allergies*
History of Pathology (i.e. any injuries, surgery, cancers, current aches, pains or tension)
1. List Areas of any Discomfort or Pain*
2. Describe Onset of Discomfort or Pain*
(i.e. how and when it started, what happened)
3. Level of Pain Today*
4. Frequency - please select the most accurate*

ConstantOff/OnAt RestWith ActivityN/AOther
5. At what time of day is the pain at its worse?*

MorningAfternoonEveningDuring SleepN/AOther
6. Have you ever injured this area before?*
8. If yes, list all related treatments received for the injury.
7. Have you ever been in an accident (automobile, work, falls, etc.) ?*
9. Have you ever received therapeutic massage for a specific problem or injury?
Was the treatment used effective?
10. Is there anything that you do that creates, increases or decreases pain? *
11. What are the physical duties required of your occupation?*
12. What activities/hobbies do you enjoy?*
13. How are your energy levels currently on a scale from 1 (low) to 10 (high)?*
14. How are your sleep patterns and how many hours do you sleep per night?*
15. Please list exercise and stress reduction / relaxation activities (including frequency).*
16. Do you take any of the following intoxicants?*

AlcoholCaffeineNicotineRecreational drugsOther
17. If you ticked any of the boxes above please state quantity and frequency of use*
Type N/A if not
18. In what position do you most often wake up?

BackSideStomachOther
19. Are you currently seeing any other healthcare professional? *
20. Please describe your typical daily diet and fluid (water, juice, herbal tea) intake*
Please check any symptoms that apply to you and indicate right or left when applicable:
Head

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
Shoulders

Pain in shouldersFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther
Mid-Back

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Hip

Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Legs and Feet

Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
Please check any of the following conditions that apply to you:
Circulation

High blood pressureLow blood pressureVaricose veinsOedemaBlood disorderPrevious Heart attackDeep Vein ThrombosisArteriosclerosisHaemophiliaPoor circulationOther
Skin

EczemaPsoriasisInfectionParasitesBruisesBlistersAcneOther
Skeletal (bones)

BreaksFracturesOsteoporosisRheumatismArthritisPostureOther
Musclular

SprainStrainSlipped discMuscle tearOther
Neurological

EpilepsyHeadachesMigrainesPrevious stroke / T.I.A.Other
Endocrine (Hormonal, glandular)

DiabetesHypothyroidHyperthyroidOther
Respiratory

AsthmaHayfeverInfectionOther
Digestion

I.B.S.ConstipationOther
Gynaecological

Currently menstruatingP.M.SOther
Current or History of Cancer
Have you had, or do you have a diagnosis of cancer?*

No, I have never had cancerYes, I have had cancer in the pastYes, I am currently dealing with cancer
What area was the cancer found and explain what type of treatment was used and when was your last treatment?
Massage Policies: Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please turn off your mobile phone for optimal relaxation

• Your scheduled session is set aside for you. We do not double book appointments

• Please reschedule your session if you are more than 15 minutes late

• 24 hour cancellation notice is required to avoid being charged for your session

• You will be draped and at no time will genitalia or breast tissue be exposed

• You will have a prior consultation with your therapist to discuss your session

• Should the session require, after your therapist has left the room, you may disrobe to your comfort level

• I understand that my therapeutic massage therapist or I may end the session at any time for any reason

• Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law. If your therapist feels uncomfortable or you feel uncomfortable at any time, it should be made known and another instance will terminate the massage.

Client Agreement: I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. It is my choice to receive therapeutic massage as a form of therapy. I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status. I understand that my failure to do so may post a threat to my health and/physical well being and I hold Benevolent Care and Touch LLC and my therapeutic massage therapist from any liability whatsoever arising from failure on my part. By my electronic signature below, I agree to the massage policy and client agreement above.
Signature*

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Current or History of Cancer