Black Rock Therapies New Client Intake

Client Intake Form
All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name*
First NameLast Name
How did you hear about us? Who referred you to us?*
BNIAnother ClientNewspaperRadioKinsmen Dreamhome 50/50Signage / Drive-bySocial MediaGoogle SearchWebsiteOther
If a BNI member or another client referred you, please list their name so we can credit them for a referral.
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Birth Date*
DayMonthYear
E-mail
E-mail me the following communications:
Monthly Clinical UpdatesAppointment Confirmations
Cell Number*
Text Me for Appointment Confirmations
Occupation
List any Allergies you may have
1. Reason for today’s visit - What is the Main Complaint?
2. Describe Onset of the Main Complaint
3. Rate the level of your Pain today
4. Frequency - please select the most accurate
ConstantOff/OnAt RestWith ActivityOther
5. At what time of day is the pain at its worse?
MorningAfternoonEveningDuring SleepOther
6. List all related treatments received for the Main Complaint
7. Have you injured this area before? If yes, how?
8. List any previous accidents, injuries or surgeries?
9. Have you received previous therapeutic massage therapy?
Was the treatment used effective?
10. Have you received previous manual osteopathic therapy?
Was the treatment used effective?
11. Is there anything that you do that increases or decreases pain?
12. What activities/hobbies do you enjoy?
13. Please list exercise and stress reduction activities (including frequency).
14. In what position do you most often wake up?
Right SideLeft SideStomachBack
15. Are you currently seeing any other healthcare professional?
16. Do you experience any of the following symptoms?
DizzinessFaintingLight-headednessPain in earsRinging in earsOther
17. Do you experience Head Pain? If yes, where is the most common location?
18. Do ANY of the following apply to you?
Artificial JointBlood Pressure HighBlood Pressure LowBlood Thinner MedicationBreast Augmentation or ReductionBursitisCannabis Use - CBD or THCCarpal Tunnel SyndromeCPAP MachineCurrent Cancer TreatmentCurrently Pregnant
Contined
Currently Smoke or VapeDiabetes - Type 1 or 2Epilepsy EpisodesFibromyalgiaPacemakerIntrauterine DeviceOpen sores or woundsOsteoporosisPins or PlatesShinglesTMJ Disorder
19. Do you experience any of the following Neck symptoms?
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
20. Do you experience any of the following Shoulder symptoms?
Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
21. Do you experience any of the following Arms & Hands symptoms?
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
22. Do you experience any of the following Mid-Back symptoms?
Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
23. Do you experience any of the following Low Back symptoms?
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
24. Do you experience any of the following Hip symptoms?
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
25. Do you experience any of the following Legs and Feet symptoms?
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
Treatment Policy:
Client services and chart information are confidential. Written authorization is required from you to release any information.
       • Please turn off or silence your cell phone
       • Please reschedule your session if you are not feeling well
       • Please reschedule your session if you are more than 15 minutes late
       • Minimum 3 hour cancellation notice is required to avoid being charged for your session
       • You will be draped for MASSAGE THERAPY and at no time will genitalia or breast tissue be exposed
       • Your therapist will begin your session with a consultation to discuss your session
       • I understand that my therapist or I may end the session at any time for any reason
       • Inappropriate behavior will not be tolerated

Client Agreement:
I understand that Massage and Manual Osteopathic therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment or any pharmaceuticals.
I acknowledge that Massage and Manual Osteopathic therapies are not substitutions for medical examination or diagnosis, and it is recommended that a physician be seen for that service.
It is my choice to receive Massage and/or Manual Osteopathic therapy as a form of therapy.
I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction, to encourage a state of relaxation and to restore functional movement where possible.
I undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapist so they adjust their technique.
I understand that any cancelled appointment within 3 hours from the start time will be considered a Short Notice Cancellation.
I understand that I am financially responsible for the full cost of any Short Notice Cancellation and No Show appointments.
I understand that Black Rock Therapies offers the service of direct billing to all major insurance companies but if for whatever reason the insurance company does not cover full or partial costs of the treatment that I wll be responsible for any outstanding amount.
I have stated my pertinent health conditions, and will update the 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 harmless Black Rock Therapies and my therapist from any liability whatsoever arising from failure on my part.
By my electronic signature below, I agree to the Treatment Policy and Client Agreement above.
Signature*
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