Sarah Rose Therapies Client Intake Form

Client Intake Form
All information is held 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.
Name
First NameLast Name
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Birth Date
MonthDayYear
Phone Number*
E-mail*
Emergency Contact*
Phone Number*
Occupation
Doctors Name and phone number
Medications
Allergies
Health Information
Are you currently pregnant or breastfeeding?
PregnantBreastfeeding
Please indicate if any of the following apply to you.
CancerHeadaches/migrainesArthritisDiabetesJoint ReplacementHigh/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains/StrainsDigestive ProblemsDo you work at a computer?StressRegular Sleep PatternAnxietyDepressionInflammationOther
What would you like to achieve from your appointment? E.g. Relaxation or Specific areas of concern*
What Pressure to you prefer?
RelaxingMediumDeepA combination of all 3
Frequency of pain or concern - please select the most accurate*
ConstantOff/OnAt RestWith ActivityOther
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 shoulderFrontBackSidePain 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 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
Client Agreement:
I understand that therapeutic massaage, reflexology,enegy 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 holistic therapies are 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 treatments as a form of therapy.
I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic 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 harmless Pure Touch Therapy 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.
Please Tick if you would like to receive information on special offers from Sarah Rose Therapies.
Yes please
Signature*
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Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Date*
MonthDayYear
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