Questionnaire - Luke Hitchman

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Intake Form

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Occupation

Treatment Goal

Have you received massage therapy before?

Yes

No

If yes, which type of massage therapy?

Are you on any medication?

Yes

No

If yes, please list medications:

Do you have any allergies?

Yes

No

If yes, please list allergies:

List any sport, exercise or repetative movement you do:

Please mark any of the following conditions you may have

Recent surgery

Diabetes

Arthritis

Cancer

Osteoporosis

Heart conditions

Spinal conditions

Digestive conditions

Fibromyalgia

Chronic fatigue

Epilepsy

Sports injury

High blood pressure

Low blood pressure

Varicose veins

Swelling

Bursitis

Asthma

Headaches

Trapped nerve

Pregnancy

Depression

Anxiety

Chronic pain

Acute pain

Other condition

If condition not listed, please give details:

Consent(Required)

I hereby state that, to the best of my knowledge, all my answers are correct. I understand that my personal health information will be collected, and that all information that I provice will be kept confidential unless required by law. I will inform the therapist of my current condition at the time of each visit.