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Intake Form

Please complete & submit the following form before your session.

Today's Date

Date of Initial Visit

Referred by

Personal Information

First Name

Last Name

Date of Birth

Email

Phone

Street Address

Street Address Line 2

City

State

Zip

Physician

Physician's Name

Physician's Phone #

Emergency Contact

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Additional Details

How Would you rate your general health?

Excellent

Good

Fair

Poor

Have you had a professional massage before?

Yes

No

If yes, date of last treatment

List current medications & the conditions they are treating

List any major accidents or surgeries (including dates)

Any allergies or hypersensitivies?

Reason for Initial Visit

Conditions

HEAD NECK

Headaches / Migraines

Ringing in Ears

Vision Problems

Vertigo / Dizziness

Vision Loss

RESPIRATORY

Asthma

Shortness of Breath

Chronic Cough

Bronchitis

Emphysema

Sinusitus

Frequent Colds

Smoker

Family History of Respiratory Difficulties

NERVOUS SYSTEM

Sensory Loss / Change

Numbness / Tingling

Sciatica

Epilepsy

Seizures

Multiple Sclerosis

OTHER CONDITIONS

Cancer

Diabetes

Unexplained Weightloss

Digestive Conditions

Fibromyalgia

Chronic Fatigue Syndrome

Depression

Anxiety

Psychiatric Disorder

CARDIOVASCULAR

High Blood Pressure

Low Blood Pressure

Heart Attack

Stroke

Heart Disease

Poor Circulation

Phlebitis / Varicose Veins

Pacemaker

Hemophilia

Chronic Congestive Heart Failure

Family History of Cardiovascular Problems

SKIN & INFECTIONS

Hepatitis

HIV / AIDS

Herpes

Tuberculosis

Lyme Disease

Infectious Skin Conditions

MUSCULOSKELETAL SYSTEM

Arthritis

Family History of Arthritis

Osteoporosis

Tendonitis

Bursitis

Jaw Pain (TMJ)

Pins / Plates / Wires / Artificial Join

REPRODUCTIVE

Pregnant

Given Birth

Gynecological Problems

Other Conditions Not Listed

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.

Your Signature

Thanks for submitting, keep a lookout for an email on what to expect at your first appointment.

Don't forget to check your spam folder for an email from joannemuir@joannemuir.com

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St. Pete Office

(Resonate Sound Healing)

919 49th St S, Gulfport

Tampa Office

(Keller Williams Building - 2nd Floor)

3502 Henderson Blvd

joannemuir@joannemuir.com

© 2021 Joanne Muir. All Rights Reserved.

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