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CONFIDENTIAL CLIENT INTAKE FORM
Date of Initial Visit: ______
Name: ______
Street Address______
City______State______Zip______
Home Phone______Work/Cell______email______
Date of Birth:______Age:______Occupation______
Marital Status:______Are you pregnant? Y N Date of last menstrual cycle:______
Any known allergies to oils/essential oils/herbs? Y N If so, please note______
On medications?______Received prior massage/bodywork? Y N Indicate types:______Referred by: ______
REASON FOR VISIT
What is your primary concern?______
What are other areas of concern?______
When did you first notice it?______What brought it on?______
Describe any stressors occurring at the time:______
What activities provide relief?______what makes it worse?______
Is this condition getting worse? ______interfere with work?______sleep?______recreation?______
Describe your exercise routine (type, frequency)______
FAMILY HISTORY
Partner: Alive Age:____ Deceased Age:_____ How long ago?_____ Major Health Issues:______
Mother: Alive Age:____ Deceased Age:______How long ago?_____ Major Health Issues:______
Father: Alive Age:____ Deceased Age:______How long ago?_____ Major Health Issues:______
Siblings: ______Major Health Issues?______Your Birth Order: Eldest Middle Youngest
Maternal Grandmother: Alive Age:____ Deceased Age:_____ Major Health Issues:______
Maternal Grandfather: Alive Age:____ Deceased Age:_____ Major Health Issues:______
Paternal Grandmother: Alive Age:____ Deceased Age:_____ Major Health Issues:______
Paternal Grandfather: Alive Age:____ Deceased Age:_____ Major Health Issues:______
Children: Y N Indicate sex, age, major health issues:______
______
Family History of Abuse: Y N circle if applicable: physical emotional sexual spiritual
Family History of Substance Abuse: Y N Suicide: Y N Other trauma:______
MEDICAL HISTORY
Are you currently under the care of another health care provider(s)? Y N Reason:______
______
Name(s) of Practitioner______
Address:______Phone:______email:______
Current Medications:______
Allergies: specify allergen and reaction: ______
______
Supplements/Remedies______
Do you use: Tobacco?_____ Qty:_____/ppd Alcohol?____ Qty______ounces/day/week/month Marijuana?____Qty:__
Other?______Treated for substance abuse? Y N Describe______
Surgical History (year and type):______
______
Hospitalizations:______
Accidents or Traumas:______
Falls/injuries to sacrum/head/tailbone (describe)______
Birth Trauma if known:______
If you are CURRENTLY experiencing any of the following, please CIRCLE
If you have experienced any of the following in the PAST, please UNDERLINE
Headaches (migraine, tension, cluster)AsthmaSinus Conditions
Ringing in Ears Swollen AnklesSciatica
Pins and needles in arms, legs, hands or feetSeizuresPainful joints
Cold Hands or Feet AnxietyFatigue
Loss of Smell or TasteSpinal problemsFainting spells
Skin Disorders (acne, fungus, psoriasis, other)Loss of memoryDepression
High or low blood pressureTrouble sleepingContact lens
Frequent colds/upper respiratory conditionsDenturesArtificial/missing limbs
Muscular tightness (location)______Swollen joints
Varicose Veins (location)______
Mark any areas of current persistent pain or tension on the figures below:
Self Care
Digestion & Elimination
Typical Breakfast: ______
Typical Lunch: ______
Typical Dinner:______
Snacks:______Water Intake (glasses/day)______Caffeine______
What is the worse thing on your diet?______What foods are your weakness?______
Are you subject to binge eating?______If so, what foods?______
Do you experience bloating / gas / burps after eating? Y N What foods trigger this?______
How often are your bowel movements? ______Do your stools: sink float
Constipation?______Blood in stool?______mucus in stool?______Pain when stooling?______
Supplements:______
Other concerns:______
Emotional & Spiritual
What is your opinion of yourself?______
Please describe the most negative emotion you experience______
When do you most often feel this emotion?______Typically, where are you?______
Do you pray or have a spiritual practice?______
On a scale of 1-10 (1 being the lesser, 10 the greater), please rate yourself in the following areas:
Faith______Hope______Charity______Generosity______Sense of Humor______Sense of Fun______
Fear______Grief______Other (please describe)______
What hobbies/activities provide you with a sense of pleasure and accomplishment?______
What are ways in which you take care of yourself?______
What changes would you like to achieve in 6 months?______One year?______
FEMALE REPRODUCTIVE HEALTH HISTORY
Age of Menarche______What was this like for you?______
How many pregnancies have you had? ______Number of deliveries______Date(s):______
Termination(s):______Date(s):______Miscarriage(s):______Date(s):______
Complications:______
What was your experience of: Pregnancy?______
Labor?______Delivery:______
Post Partum?______Did you nurse? Y N If so, how long?______
Method of Contraception (circle): pills patch diaphragm injection condoms IUD abstinence rhythm method
Other:______Length of time on pills, patch, injection or IUD: ______
Last pap smear: ______Results: ______Date of Last Menstrual Period: ______Length:______
Cycle length:______Episodes of amenorrhea (no menses)? Y N If yes, when & how long?______Any known medications your mother took when she was pregnant with you?______
Maternal Family History (circle): infertility fibroids endometriosis cancer (type):______menstrual problems
Menopausal symptom(s) (type):______PMS (type):______
Menses Difficulties: (circle if currently experiencing; underline if experienced in past)
Painful periodsIrregular (late or early)
Dark thick blood at beginning/end of cycleDizziness with period
Headache or migraine with periodExcessive bleeding (> one pad/hour)
PMS/depression with or before periodFailure to ovulate
Painful ovulationBloating/water retention with period
Heaviness or pressure in lower pelvis with period
Other Symptoms (circle & describe if currently experiencing; underline if experienced in past)
Varicose veins of legTired weak legs
Numb legs and feet when standing stillSore heels when walking
Low back achePainful intercourse
ConstipationEndometriosis
Uterine PolypsFibroids (size & location) ______
Uterine infectionsFrequent urination
Bladder infectionsVaginal discharge (describe)
VaginitisPremature deliveries
Weak newborn infantsDifficult pregnancy
Incompetent cervixSpotting with pregnancy
Pelvic inflammationSexually transmitted disease (date & type)______
Dry vaginaCysts: ovarian breast
Cancer: cervix bladder uterus ovarian bowel
Are you under treatment for infertility? Y N Describe current treatment to date (IUI, IVF, etc): ______
______
Gynecological Provider:______Address:______Phone:______
Rate your interest in sex: High Moderate Low None
Do you have or ever had difficulty experiencing orgasms?______
Have you experienced a history of: rape trauma incest If so, when?______
Did you undergo counseling for this? Y N What was this like for you?______
MENOPAUSE SYMPTOMS (circle & describe if currently experiencing; underline if experienced in past)
Hot flashesInsomniaFatigueMemory Loss
Mood SwingsIrritabilityDry VaginaDepression
Spotting (menses)FloodingClottingIrregular mensus
Increased libidoDecreased libidoVaginal discharge (describe):______
Other symptoms not listed: ______
______
When did these symptoms begin?______Are they getting worse?_____ Better?______Same?______
Last menstrual period ______Are you on, or have you ever been on, hormone replacement therapy?____
If so, how long?______Name and dose ______
If stopped, reason? ______
Other medications/herbal remedies taken for symptoms?______
Age of Mother at menopause? ______Concerns/experience______
Additional comments:
CONFIDENTIAL CLIENT INTAKE FORM (M)
Date of Initial Visit: ______
Name: ______
Street Address______
City______State______Zip______
Home Phone______Work/Cell______email______
Date of Birth:______Age:______Occupation______
Marital Status:______# of children living at home:______
Any known allergies to oils/essential oils/herbs? Y N If so, please note______
Received prior massage/bodywork? Y N Indicate types:______
Referred by: ______
REASON FOR VISIT
What is your primary concern?______
What are other areas of concern?______
When did you first notice it?______What brought it on?______
Describe any stressors occurring at the time:______
What activities provide relief?______what makes it worse?______
Is this condition getting worse? ______interfere with work?______sleep?______recreation?______
Describe your exercise routine (type, frequency)______
FAMILY HISTORY
Partner: Alive Age:____ Deceased Age:_____ How long ago?_____ Major Health Issues:______
Mother: Alive Age:____ Deceased Age:______How long ago?_____ Major Health Issues:______
Father: Alive Age:____ Deceased Age:______How long ago?_____ Major Health Issues:______
Siblings: ______Major Health Issues:______
Maternal Grandmother: Alive Age:____ Deceased Age:_____ Major Health Issues:______
Maternal Grandfather: Alive Age:____ Deceased Age:_____ Major Health Issues:______
Paternal Grandmother: Alive Age:____ Deceased Age:_____ Major Health Issues:______
Paternal Grandfather: Alive Age:____ Deceased Age:_____ Major Health Issues:______
Children: Y N Indicate sex, age, major health issues:______
______
Family History of Abuse: Y N circle if applicable: physical emotional sexual spiritual
Family History of Substance Abuse: Y N Suicide: Y N Other trauma:______
MEDICAL HISTORY
Are you currently under the care of another health care provider(s)? Y N Reason:______
______
Name(s) of Practitioner______
Address:______Phone:______email:______
Current Medications:______
Allergies: specify allergen and reaction: ______
______
Supplements/Remedies______
Do you use: Tobacco?_____ Qty:_____/ppd Alcohol?____ Qty______ounces/day/week/month Marijuana?____Qty:__
Other?______Treated for substance abuse? Y N Describe______
Surgical History (year and type):______
______
Hospitalizations:______
Accidents or Traumas:______
Falls/injuries to sacrum/head/tailbone (describe)______
Birth Trauma if known:______
If you are CURRENTLY experiencing any of the following, please CIRCLE
If you have experienced any of the following in the PAST, please UNDERLINE
Headaches (migraine, tension, cluster)AsthmaSinus Conditions
Ringing in Ears Swollen AnklesSciatica
Pins and needles in arms, legs, hands or feetSeizuresPainful joints
Cold Hands or Feet AnxietyFatigue
Loss of Smell or TasteSpinal problemsFainting spells
Skin Disorders (acne, fungus, psoriasis, other)Loss of memoryDepression
High or low blood pressureTrouble sleepingContact lens
Frequent colds/upper respiratory conditionsDenturesArtificial/missing limbs
Muscular tightness (location)______Swollen joints
Varicose Veins (location)______
Mark any areas of current persistent pain or tension on the figures below:
Self Care
Digestion & Elimination
Typical Breakfast: ______
Typical Lunch: ______
Typical Dinner:______
Snacks:______Water Intake (glasses/day)______Caffeine______
What is the worse thing on your diet?______What foods are your weakness?______
Are you subject to binge eating?______If so, what foods?______
Do you experience bloating / gas / burps after eating? Y N What foods trigger this?______
How often are your bowel movements? ______Do your stools: sink float
Constipation?______Blood in stool?______mucus in stool?______Pain when stooling?______
Supplements:______
Other concerns:______
Emotional & Spiritual
What is your opinion of yourself?______
Please describe the most negative emotion you experience______
When do you most often feel this emotion?______Typically, where are you?______
Do you pray or have a spiritual practice?______
On a scale of 1-10 (1 being the lesser, 10 the greater), please rate yourself in the following areas:
Faith______Hope______Charity______Generosity______Sense of Humor______Sense of Fun______
Fear______Grief______Other (please describe)______
What hobbies/activities provide you with a sense of pleasure and accomplishment?______
What are ways in which you take care of yourself?______
What changes would you like to achieve in 6 months?______One year?______