Massage Therapy Initial intake form First Name*Last Name*DOB(Month/Day/Year)* Date Format: MM slash DD slash YYYY Sex*MaleFemalePhoneHome*Mobile*WorkAddressOccupation*Email Address* Emergency ContactName*Relation*Phone*Family Doctor DetailsDo you have a family doctor?*YesNoName*Phone*Doctor Address*How did you hear about us?*GoogleLook LocalDrive byDoctor ReferalFriend/FamilyOtherPlease describe how you heard about us*What is your primary complaint that you are seeking Massage Therapy for?Briefly explain your concerns*Primary Insurance coverageInsurance Company namePolicy holders namePolicy Holders DOB (YYYY/MM/DD) Date Format: YYYY slash MM slash DD Plan/ Contract #Certificate/ ID#Current treatment with other practitionersList all Sports/ ActivitiesHealth History Please check the boxes for any condition(s) you have experienced or are experiencing: Update your therapist if anything changes in your healthRespiratory Chronic cough Shortness of breath Bronchitis Asthma Emphysema N/A Cardiovascular High / Low Blood pressure Heart attack Phlebitis Stroke Pacemaker Heart disease Easy bruising- use of blood thinning medication (Warfarin, Coumadin etc) Varicose veins Blood clots Poor circulation N/A Infections Hepatitis TB HIV/ AIDS Skin Other N/A Please Specify*Soft tissue/ Joint discomfort Neck Low back Mid back Upper back Shoulders Elbows Wrists/ hands Arms Hips Knees Ankle/ feet Legs Muscle cramping Jaw Weakness or paralysis Numbness Other Where*Where*Please Specify*Head/ Neck Vision problems Ear problems (ex: ringing, loss) Head trauma Headaches/ Migraines Sinus problems Past whiplash injury N/A Women Pregnant Currently Breastfeeding Menstrual Back aches Painful periods Birth control N/A (due)*Other Conditions Diabetes Epilepsy Cancer Rheumatoid Arthritis Osteoarthritis Spinal conditions Chronic fatigue Weight loss or gain Disc herniation Osteoporosis Scoliosis Bone disease Skin Condition Skin Irritations Allergies Loss of sensation Numbness/ Tingling Dizziness/ fainting Bladder or bowel changes Severe pain Pain unaffected by change in position or medication Pain with no history of injury Severe spasm Difficulty speaking or swallowing Recent nausea or vomiting N/A Type*Onset*Please Specify*Smoke? Yes No What is your general health status?*Artificial Joints, Pins, wires?*Medication*I don't take medicationI will provide a list to be photocopied on my visitYes I take medicationList all current medication you are taking*(**You may also provide a list to be photocopied by our reception staff)List all Past Surgeries*Internal pins, wires, artificial joints, special equipment?Payment information: Payment for services at Footprint Health and Wellness are the responsibility of the patient and are to be paid at each visit. If a third party payer denies your claim and/or refuses to pay for the full amount billed, you are responsible for paying the outstanding amount.Cancelation policy: Minimum of 24 hours notice is required to cancel or change an appointment. A charge may be applied if less then this is provided. Should you book an appointment and not attend, you are responsible to pay the entire cost of the appointment.Informed consent: Footprint Health and Wellness is a multi-disciplinary health center where all the practitioners work together to provide optimal and thorough care and treatment. All handling of your information is compliant with existing College of Massage Therapists of Ontario guidelines, Provincial and Federal legislation.Is Patient Under the Age of 18?*YesNoPrint Name*Parent/ or Guardian Name*Date* Date Format: MM slash DD slash YYYY Signature*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.