Intake Form

Please Print and Fill out Intake form for our records

Confidential Health Intake Form

Name ___________________________ Date of Birth ______________________

Street Address _______________________ City____________

State_____ Zip________

Work Phone_______________Home Phone_______________Cell_____________

Emergency Contact____________________Email__________________________

Employer _________________________

Social Security Number ____________________

CURRENT HEALTH ISSUES

What is your main reason for having a Session?

Has anything changed or become worse recently?

What treatment have you received, when and from whom?

List in order of importance any other health problems that are troubling you.

Please circle which type of therapist you have seen:

Naturopathic Doctor Chiropractor Massage therapist

Acupuncturist Shaman Other

What were the results?

CURRENT HEALTH INFORMATION

Height: Current weight:

Circle any that you are currently using:

Alcohol Antacids Coffee Laxatives

Sedatives Tobacco Recreational drugs

Are you currently using any non-prescription drugs, vitamins, herbs, homeopathic remedies?

Please list the three most significant, stressful events in your life, from the most recent to distant.

1. Date:________

2. - Date:________

3. Date:________

Please circle any of the following you see or have seen:

Professional counsellor Psychologist Social worker Pastor

Release theapist Gestalt therapist Other

FAMILY MEDICAL HISTORY

Please circle any of the following that blood relatives have had (not including yourself):

Alcoholism	Allergies	Asthma	Arthritis	Bleeding conditions	Cancer	Diabetes
Depression	Epilepsy	Hayfever	Heart conditions	Heart attack	High blood pressure	Kidney conditions
Mental disorders	Obesity	Stroke	Substance abuse	Tuberculosis	Thyroid conditions

For the following sections, please circle any of the following that you have now or have had in the past.

PAST MEDICAL HISTORY

Measles	Mumps	Chicken pox
Diphtheria	Rheumatic fever	Whooping cough
Small pox	Rubella	Scarlet fever
Alcoholism	Abuse	Addiction
Diabetes	Anemia	High blood pressure
Chronic infections	Depression	Gout
Hepatitis	Jaundice	Leukemia
Malaria	Multiple sclerosis	Mumps
Polio	Typhoid fever	Weight problems
Eczema/Psoriasis	Abscess

AREAS OF PAIN AND DISCOMFORT

Please indicate areas of discomfort & areas of chronic, re -occurring pain:
Mark X for pain & Mark O for discomfort

Is there an area of major concern that you want to improve? List where.

________________________________________________

HEAD

Headaches/migraine	Stroke	Visual problems	Cataracts	Glaucoma	Hearing loss

Ringing in ears	Ear infections	Loss of taste	Thyroid problems	Cold sores	Canker sores

Allergies	Hayfever	Influenza	Fainting	Sinusitis	Strep throat

CHEST

Heart disease	Chest pain/angina	Palpitations/murmurs	Asthma	Pneumonia

Tuberculosis	Mononucleosis	Emphysema	Heart attack

EXTREMITIES

Cold hands & feet	Numbness/tingling	warts
Varicose veins	Arthritis	soreness in the muscles
soreness in the bones	soreness in the joints

DIGESTIVE

Heartburn	Nausea/vomiting	Diarrhea/Constipation
Gallstones	Excessive Gas	Bloating
Blood in stools	Muccous in stools	Undigested food in stools
Black stools	Light-colored stools	Strong odour od stools
Hemorrhoids	Parasities	Rectal Bleeding

KIDNEYS AND BLADDER

Inability to urinate/incontinence	Frequent urination	Blood in Urine
Cloudy urine	Bladder infections	Burning during urination
Kidney disease

HOUSEHOLD/OCCUPATIONAL

Please circle if any of the following apply to your home:

What type of water do you drink?

Tap Bottled Filtered Reverse osmosis Distilled

PERSONAL HABITS

With whom do you currently live?

Spouse Partner Parents Friends Children Alone

What are your hobbies and interests?

What do you enjoy most in your life?

What do you worry about the most?

How content are you with your life? (10=very content)

1 2 3 4 5 6 7 8 9 10

How often do you have leisure time? Once/day Every other day Once/week Other

Do you find your work fulfilling? Yes / No Do you take vacations? Yes / No

Do you exercise regularly? Yes / No Type: Duration: Frequency:

How is your energy level on a scale of 1 to 10 (1= low energy and 10=high energy):

When you get up in the morning 1 2 3 4 5 6 7 8 9 10

Mid-morning 1 2 3 4 5 6 7 8 9 10

Afternoon 1 2 3 4 5 6 7 8 9 10

Evening 1 2 3 4 5 6 7 8 9 10

Night 1 2 3 4 5 6 7 8 9 10

Do you reguarly release your feelings constructively? How do you release your feelings?

How would you rate your quality of sleep on a scale of 1 to 10 (10=excellent)

1 2 3 4 5 6 7 8 9 10

How many of hours of sleep do you get each night?

Do you have trouble falling asleep or staying asleep? Yes / No

Do you need a nap during the day? Yes / No

Do you ever feel dizzy when getting up quickly from a sitting or lying position? Yes / No

Would you describe how you normally feel as?

Cooler Warmer Average

How often do you get colds, flu, or sore throats in a year?

Is there anything else that you feel I should know about you?

I understand that the massage/bodywork/release work I will receive is provided for the basic purpose of relief from stress and muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that pressure or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork/release should not be considered a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified health care specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of a session should be considered as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and have answered all questions honestly. I agree to keep the practitioner informed of any changes to the above profile and understand that there shall be no liability on the practitioner‘s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment for the full time scheduled. I agree to honor the 24-hour cancellation policy or else be responsible for payment of 50% of the appointment fee that would have been due.

Client Signature Date

Practitioner Signature Date

Thank you for taking the time to complete this questionnaire. This information is important for your overall assessment and will be kept in strict confidence.

Namaste Arthur Munyer