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Intake Form
Intake Form
SpiderSavvy
2021-06-15T10:31:48-04:00
Name
First
Last
Date Of Birth
MM slash DD slash YYYY
Referred by
Email
Mobile Phone
Home Phone
Work Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Emergency Contact Name
First
Last
Emergency Contact Phone
Emergency Contact Relationship
Physician’s Name
First
Last
Physician’s Phone
Date of Initial Visit
MM slash DD slash YYYY
How would you rate your general health?
Excellent
Good
Fair
Poor
Have you had a professional massage before?
Yes
No
List current medications & the conditions they are treating
List any major accidents or surgeries (including dates)
Please tell us about any allergies or hypersensitivities
Reason for initial visit
HEAD NECK
Headaches / migraines
Vertigo / dizziness
Hearing loss
Vision problems
Vision loss
Ringing in ears
CARDIOVASCULAR
High blood pressure
Heart attack
Phlebitis / varicose veins
Chronic congestive heart failure
Family history of cardiovascular problems
Low blood pressure
Stroke
Poor circulation
Pacemaker
RESPIRATORY
Asthma
Chronic cough
Emphysema
Frequent colds
Family history of respiratory difficulties
Shortness of breath
Bronchitis
Sinusitis
Smoker
SKIN & INFECTIONS
Hepatitis
Herpes
Lyme disease
HIV / AIDS
Tuberculosis
Infectious skin conditions
NERVOUS SYSTEM
Sensory loss / change
Sciatica
Seizures
Numbness / tingling
Epilepsy
Multiple sclerosis
MUSCULOSKELETAL SYSTEM
Arthritis
Osteoporosis
Bursitis
Pins / plates / wires / artificial joint
Family history of arthritis
Tendonitis
Jaw pain (TMJ)
REPRODUCTIVE
Pregnant
Given birth
Gynecological problems
OTHER CONDITIONS
Cancer
Unexplained weight loss
Fibromyalgia
Depression
Psychiatric disorder
Diabetes
Digestive conditions
Chronic fatigue syndrome
Anxiety
Consent
I agree
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis.
I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.
I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.
Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.
Signature
First
Last
Date
MM slash DD slash YYYY
Δ
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