Massage Reiki Intake | Holistic Health Associates

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Legal Full Name of Patient*
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Preferred Name
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Date of Birth*
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Day
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Address*
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Consent to leave a voicemail?*
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- I consent to receiving SMS text messages from Holistic Health Associates on my cell phone.
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See SMS Terms & Conditions. I can change my decision for consent at any time by providing consent in writing to contactus@hhamd.com.
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Language*
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Primary Care Doctor
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Average Blood Pressure Reading
We want to do everything we can to make you comfortable. Do you require additional accomodations?*
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- No
If yes, please describe
Are you currently pregnant?*
- Yes
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Do you have issues climbing stairs? (we have upper level treatment rooms)*
- Yes
- No
How did you hear about us?*
Google/Internet Search Patient Referral Social Media Postcard Mailing Yelp Sign Ad in Local Publication Health Fair
Referral – Who?

	Currently/Recently	In the Past
Under a Doctor’s or Therapist’s Care
Previous Massage
Allergies
Arthritis/Gout
Neck/Back Problems
Sciatica
Spondylitis/Spondylolithesis, Scoliosis
Shoulder/Arm Problems
Skin Problems
Blood Pressure Problems
Implants
Cancer/Tumors
Chronic Pain/Cramping
Wear Contact Lenses
Emotional Changes/Depression/Grieving
Diabetes or Hypoglycemic
Headaches or Migraines
Phlebitis/Blood Clots
Heart Attack
Hernia
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Neurological Diseases
TMJ (Diagnosed Jaw Dysfunction)
Varicose Veins/Edema (Persistent Swelling)
Osteoporosis
Surgery
Recent Injuries/Accidents
Prior Injuries/Accidents
Pregnant/Trying
Taking Medications
Pacemaker
Epilepsy
Previous Reiki experience
Sensitivity to touch