Massage Reiki Intake | Holistic Health Associates

Name
This field is for validation purposes and should be left unchanged.
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
Cell Phone*
Home
Work Phone
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.
Email*
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/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
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