Mindful Healing

Confidential Intake Form

Welcome! I would like your session to be pleasant and comfortable. If you have a question, please ask me anytime.

Name ______Date ______

Address ______

E-mail ______Primary Phone______

Occupation ______Work Phone ______Emergency Contact______Emergency Phone ______

Activities/Hobbies______

Have you ever received a professional massage? Yes No

Are you currently seeing a medical professional? Yes No

Are you allergic to any lotions, oils, or food ingredients? Yes No

Are you taking any medications, aspirin, ibuprofen, herbs, or supplements? Yes No

Stress Scale Today 1 2 3 4 5 6 7 8 9 10

How are you feeling today: ______

Please describe the condition/problem for which you seek relief. ______

Please list all accidents, injuries, surgeries and falls below. ______

Please mark the conditions that applies to you, and if applicable rate the pain scale. Pain scale from 1 to 10 (1 is least painful).

___ Abdominal Problems___ Allergies___ Arthritis___ Asthma

___ Ankle Problems___ Back Pain___ Bed Wetting___ Bone Spurs

___ Breast Lumps___ Breast Pain___ Breast Implants___ Bronchitis

___ Bunions___ Bursitis___ Butt Pain___ Carpal Tunnel

___ Chest Pain___ Colic___ Constipation___ Diaphragm Pain

___ Digestive Problems___ Dizziness___ Ear Problems___ Edema

___ Fatigue (Chronic)___ Fibromyalgia___ Fibroids___ Fracture (Old/ New)

___ Falls on Tailbone ___ Gallbladder Problems___ HIV/AIDS___ Cancer, Tumors

___ Hamstring Problems___ Hay Fever___ Headaches___ Heart Problems

___ Hernia___ Hip Pain___ Hip Replacement___ Incontinence

___ Infertility___ Jaw & TMJ Problems___ Joint Replacement___ Liver Problems

___ Lung Problems___ Migraines___ Knee Problems___ Numbness

___ Orthodontia___ Fungal Infection___ Osteoporosis___ Eczema

___ Pelvic Problems___ Plantar Fasciitis___ Pregnant___ Prostate Problems

___ Rib Problems___ Sacral Problems___ Sciatica___ Scoliosis

___ Shin Splints___ Shoulder Problems___ Sinus Problems___ Tennis Elbow

___ Tinnitus___ TMJ___ Diabetes___ Other, please explain

LOCATION OF PAIN:

INDICATE WITH X ON ANATOMICAL DRAWING AT THE SITE OF PAIN

R L R R L L

I have read the above information and have stated all my known medical conditions. It is my choice to receive massage or Bowenwork therapy. I take it upon myself to update my therapist regarding any changes in my condition and to communicate with my therapist if at anytime I feel my comfort or safety compromised. I understand that the therapy given here is not a replacement for medical care and that no medical diagnosis will be made. I understand that Bowenwork and massage therapy involves physical touch.

This information is confidential and will not be released without my written consent.

Signature ______Date ______

Therapist Signature______Date ______