American Specialty Health Client Information Intake

Please provide your insurance card and valid ID to your practitioner

Name: ___________________________________________________________________
DOB __________________________Mobile Number: _____________________________
Email: __________________________________________________________________________________________________
Address: ______________________________________________________ City/Zip: __________________________________
Emergency Contact: _______________________________Relation: _________________ Phone: _______________________
How did you hear about Kailua Massage Therapy? ______________________________________________________________
Name of Med Practice who referred you:__________________________________ Doctor: ____________________________
Please describe the current problem and how it began:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Is this: Work Related _____________ Auto Related _______________

N/A

How often are your symptoms present per day?

Frequently

Describe the nature of your pain:

Tingling

How is your condition changing?

Getting

Constantly

Burning
Better

Current Complaint Level (how you feel today):

Shooting

Numb

Not Changing

No Pain

Onset Date: __________________________

Dull Ache

Getting Worse

Occasionally
Sharp
N/A
7

Intermittently

Other: __________________

Other: _____________________
8

Unbearable Pain

In the past week, how much has your pain interfered with your daily activities (e.g. work, social activities, or household chores?)
No Interference

In general, how would you describe your overall health right now?

Unable to carry on any activities

Excellent

Very Good

Good

Fair

Poor

Medical Information - Please check all of the following that apply to you:
Alcohol/Drug Dependence
Osteoporosis
Recent Fever
Abnormal Weight Gain or Loss
Pain Unrelieved by Position or Rest
Dizziness/Fainting
Pain at Night
Inflammations
Tingling/numbness
High/Low Blood Pressure
Diabetes type I or II. Insulin? Y N

Muscle/Joint Pain
TMJD
Fibromyalgia
Infectious diseases
Arthritis/tendonitis
Headaches/ migraines
Glasses/Contact lenses
Joint Replacement
Heart/Circulatory Issues
Eliminatory/Urinary problems
Stroke date: ____________________

Phlebitis
Hemophilia
Skin Problems
Digestive problems
Respiratory problems
Nervous System problems
Reproductive Problems
Endocrine System Problems
Tobacco Use Frequency:________ /day
Cancer/Tumor
________________________________

Surgeries
________________________________________________________________________________________________________
Feel free to elaborate on any of the above or add new items
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Medications currently prescribed and their purpose (purpose is more important than the name):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Who have you seen for your condition before today: None GP LMT Chiropractor PT Acupuncturist Other: ____________
What treatment did you receive and when? ____________________________________________________________________
Pregnant? Y N #Weeks: __________ Due date? _______________ Doctor indicate massage? Y N First pregnancy? Y N
Allergies / skin sensitivities: ________________________________________________________________________________
Had professional massage before? Y N

If so, what kind and how long ago? ______________________________________

Any sunburn, wounds, injection sites or healing body modifications? Y

___________________________ ____________

What is your profession and/or Industry? _______________________________________________________________________

Do you ever experience physical discomfort just at work? How so?

_______________________________________________

________________________________________________________________________________________________________
Any hobbies or physical activities you do on a regular basis (gym visits, sports, gardening, and weekend warrior stuff)
________________________________________________________________________________________________________
Carefully read the consent agreement then sign/date at the bottom.

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscle tension

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure/strokes
may be adjusted to my comfort level

I further understand that the bodywork should not be construed as a substitute for medical examination, diagnosis, or
treatment and that I should see a qualified medical specialist for any mental or physical ailment of which I am aware

I understand that the bodywork practitioners are not qualified to diagnose, prescribe or treat any physical or mental illness,
and that nothing said in the course of the session should be construed as such

I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the
practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioners
part should I fail to do so

I understand that any illicit or sexually suggestive remarks or advances made by me will result in the immediate termination of
the session, and I will be liable for the full payment of session

Signature: _______________________________________________________________ date: _______________________

Mahalo!