Massage/Reiki Intake Update

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Today's Date*
Month
Day
Year
Legal Full Name of Patient*
First Last
Preferred Name
First Last
Date of Birth*
Month
Day
Year
Gender*
Pronoun
Relationship Status
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home
Cell Phone*
Work Phone
Email
Consent to leave a voicemail?*
- Home
- Cell
- Work
SMS Consent*
- I consent to receiving SMS text messages from Holistic Health Associates on my cell phone.
- I do NOT consent to receiving SMS text messages from Holistic Health Associates on my cell phone. By checking this box, I recognize that I will not be receiving any text messages from Holistic Health Associates, including appointment reminders.
See SMS Terms & Conditions. I can change my decision for consent at any time by providing consent in writing to contactus@hhamd.com.
Occupation
Employer
Language*
- English
- Spanish
Race*
Emergency Contact Name*
Emergency Contact Phone*
Primary Care Doctor
Height*
Weight*
Average Blood Pressure Reading
We want to do everything we can to make you comfortable. Do you require additional accomodations?*
- Yes
- No
If yes, please describe
Are you currently pregnant?*
- Yes
- No
Do you have issues climbing stairs? (we have upper level treatment rooms)*
- Yes
- No
How did you hear about us?*
- Google Search
- Health Fair
- Yelp
- Sign
- Frederick Lifestyle Magazine
- Other Publication
- Internet Search
- Patient Referral
Referral – Who?

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What level of conversation do you prefer in the treatment room?*
- I prefer little to no conversation during my massage
- I don’t mind conversation/feedback during my massage
What do you hope to gain from your massage sessions?

Do you have now, or have you ever had any of the following?

	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
Infectious Conditions
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

Are you currently undergoing cancer treatment?*
- Yes
- No
Anything We Missed You Want to Tell Us?
*
I UNDERSTAND THAT MASSAGE PRACTITIONERS ARE NOT TRAINED IN THE DIAGNOSIS AND TREATMENT OF DISEASES. I CONFIRM THAT I HAVE CONSULTED A MEDICAL DOCTOR FOR ALL THE CONDITIONS CHECKED AND HAVE RECEIVED AUTHORIZATIONS TO HAVE MASSAGE BY SIGNING THIS RELEASE, I DO HERBY WAIVE AND RELEAVE THE MASSAGE PRACTITIONER FROM ALL LIABILITY, PAST, PRESENT, AND FUTURE.
Signature of Patient, Legal Representative, or Parent/Guardian*
Your Name
Your Name
Your Name
Date*
Month
Day
Year
Printed Name of Patient, Legal Representative, or Parent/Guardian*
Relationship to Patient*
- Patient
- Parent/Guardian

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Cart

10-Day Reset Program
0 out of 5
$190.00
30 Min Pediatric Package Session
0 out of 5
Price range: $70.00 through $1,575.00
Red Light Therapy
0 out of 5
Price range: $100.00 through $590.00
Reset
5.00 out of 5
Price range: $125.00 through $475.00
UltraClear RENEW
0 out of 5
$134.00