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New Client Intake Form

Client Contact Information

First Name *

Last Name *

Email *

Phone *

Date of birth *

Client Address

Address *

City *

State *

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Chiropractor Contact Information (Optional)

Chiropractor Name

Chiropractor Phone

Issues to Address

Respiratory

Asthma

Chronic Cough

Shortness of Breath

Emphysema

Bronchitis

Skin

Bruise Easily

Skin Irritations

Skin Conditions

Hypersensitive Reaction

Melanoma

Head & Neck

Ear Problems

Hearing Loss

Vision Problems

Vision Loss

Headaches

Migraines

Jaw Pain (MJD)

Sinus Problem

Infectious Conditions

Athlete's Foot

Skin Conditions

Respiratory Conditions

HIV

Hepatitis

Herpes

Reproductive

Pregnancy

Gynecological Issues

Family History

Family Cardiovascular Conditions

Family Respiratory Conditions

Neurological

Burning

Numbness

Tingling

Stabbing Pain

Cerebral Palsy

Parkinsons

Multiple Sclerosis

Herniated Disc

Cardiovascular

Blood Clots

Pacemaker

Cerebral-Vascular Accident

Lymphedema

Thrombosis/Embolism

Cold Hands

Cold Feet

Varicose Veins

Low Blood Pressure

High Blood Pressure

Myocardial Infarction

Plebitis

Stroke

Cardiovascular Accident

Heart Attack

Heart Disease

Congestive Heart Failure

Miscellaneous #1

Allergies

Cancer

Dizziness

Hemophilia

Mental Illness

Surgical Pins or Wires

Anaphylaxis

Crohn's Disease

Epilepsy

Arthritis

Osteoarthritis

Rheumatoid Arthritis

Miscellaneous #2

Artificial Joint/Special Equipment

Diabetes

Fibromyalgia

Loss of Sensation

Osteoporosis

Shingles

Stress

Digestive Conditions

Insomnia

Gout

Lupus

Other Diagnosed Diseases

Other Medical Conditions

Allergies and other conditions your provider should be aware of

Medications

Do you have any questions or concerns?

Typical activities of daily living affected by condition?

Reasons for seeking a massage? (relaxation, injury, etc.)

Preferred types of massage?

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16703 Early Riser Ave
Suite #TR3, Land O' Lakes, FL 34638

(813) 682-8750

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