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HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are optional and will be kept strictly confidential

PATIENT INFORMATION First Name:

Last Name:

Sex:

 Mr.  Mrs.

Birth date:

M

F

/

Age:

 Miss  Ms.

Marital status (circle one) Single / Mar / Div / Sep / Wid

Height:

Weight:

/

Email:

Cell phone:

Work phone:

Street address:

City:

State:

ZIP Code:

Occupation:

Employer:

Employer phone:

Primary Physician:

Phone number:

Date last seen:

Emergency Contact:

Contact number:

Relationship to patient:

Chose clinic because/Referred to clinic by:  Family

 Friend

 Close to home/work

 Internet search

 Doctor

 Other:

CHIEF HEALTH CONCERN What health concern(s) are you seeking treatment for?

MEDICAL HISTORY

Have you ever been diagnosed with the following? 

Asthma

Stroke

Cancer

Seizures/epilepsy

Diabetes

Kidney disease

Hypertension

Thyroid problems

Osteoporosis

High cholesterol

Hepatitis

Arthritis

Heart disease

HIV/AIDS

Tuberculosis

Mental health issues

Allergies. Please list:

Please list any surgeries you have had: Please list any prescription medication you are taking:


MUSCULO-SKELETAL PROBLEMS Please circle problem areas

For massage

What kind of pressure do you prefer?

 Light

 Medium

 Deep

What are your goals for receiving massage

 Stress Relief

 Injury rehabilitation

 Pain relief

Onset

How long ago did pain appear?

Is the problem related to an injury?

 Yes

Nature of pain

 Comes and goes

 Constant

 With certain movements

 Sharp

 Dull

 Throbbing

 Feels hot

 Feels cold

 Physical therapy

 Chiropractic

 Acupuncture

 Massage

 Medication

 Cortisone injections

 Surgery

 Other

Other treatments received

 No

HEALTH HABITS AND LIFESTYLE Exercise

What type of exercise do you get? How frequently do you exercise?  Irregular mild exercise

Work

Stress

 Irregular vigorous exercise

 Regular mild exercise

 Regular vigorous exercise

What is the nature of your work? Mark all that apply  Sedentary

 Indoors

 Outdoors

 Physical labor

 Repetitive movements

 Mentally engaging

 High stress

 Long hours

Rank stress levels:

 Hi

 Med

 Low

Consent to treat: I understand the basic purpose of massage therapy is relaxation and relief of muscle tension and pain. If I experience any pain or discomfort during this and any following sessions, I will immediately inform Jennifer so that the pressure and/or strokes can be adjusted to my level of comfort. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in the termination of the session and I will be liable for the payment of the session.

Office Policies: I understand that Jade Spring Acupuncture & Massage will use my email address to confirm appointments and send a monthly newsletter. Further, I understand that the organization will never sell my contact information, or “spam” my email account and that at any time I have the right to request to be taken off of the organization’s mailing list. I have been notified that Jade Spring Acupuncture & Massage has a 24 hour cancellation policy. In the event that I miss an appointment without notifying Jennifer Stevenson, or cancel without due notice, I may be charged 40% of the cost of the scheduled appointment.

Patient or Guardian Name

Signature

Date


Massage intake