Mayan Abdominal Therapy MALE Intake Form

Confidential MALE Intake Form
Date of initial visit:*

MonthDayYear
Date
Name:*

First NameLast Name
Email*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact's Phone Number*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:*
Please enter a valid phone number.
Home Phone Number:
Please enter a valid phone number.
Work Phone Number:
Please enter a valid phone number.
Date of Birth:*

MonthDayYear
Date
Age:*
Anatomical Gender:*
Gender-Identity:*
Preferred Pronoun:*
Occupation:*
Marital/Relationship status:*
Referred by:*
How did you hear about us?*

Social Media (Facebook, Instagram, etc)Google SearchYelpNextdoorArlNow/Patch/etcOther
Other (name of family/friend, doctor, physician, group, etc. Put N/A if not applicable)*
Client Confidentiality and Release Form
I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health. Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release form from their client before taking any information about them. The best way to be fully compliant is to obtain this release signature at the initial consultation. Clients should receive a copy of the form they signed (upon request), and the practitioner maintains a copy for their records I, First Name* Last Name*, Street Address* Address Line 2* City* State* Zip* , give my permission, for my practitioner, to take notes including health history/ medical and /or personal information I choose to disclose to him/her. I understand this information may be used for the purpose of practitioner certification and/or may be shared with the Arvigo Institute, LLC for statistical data collection only. All relevant identifying information will not be disclosed, such as name, address, social security number, date of birth. field. Please add appropriate fields and text.
Client Signature:*

Clear
Date:*

MonthDayYear
Date
Practitioner Signature:

Clear
Date:

MonthDayYear
Date
Reason For Visit
Primary reason for visit:*
When did you first notice it?*
What brought it on?*
Describe any stressors occurring at the time:*
What activities provide relief?*
What makes it worse?*
Is this condition getting worse?*
Does it interfere with any of the following?*

WorkSleepRecreationNone of the above
Have you had massage/bodywork before?*

YesNo
If yes, what type?*
Medical History
Are you currently under the care of another healthcare provider(s)?*
Reason(s):*
Name(s) of practitioner:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Current medications and/or supplements/remedies: *
Allergies/sensitivities: specify allergens/sensitivities and reactions:*
Surgical History (year and type) and/or recent procedures:*
Hospitalizations:*
Accidents or Traumas:*
Falls/injuries to Sacrum/head/tailbone (describe):*
Other:

Please review and check the following:*

	Past	Present	None/Not applicable
Headaches
Asthma
Cold hands or feet
Swollen ankles
Sinus conditions and/or frequent colds
Seizures
Low back pain
Skin disorders
Sciatica
Painful/swollen joints
High or low blood pressure
Dentures/partials
Numbness in feet or legs when standing
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Fainting spells
Muscular tension
Varicose Veins
Hemorrhoids
Herniated/bulging discs
Artificial/missing limbs
Contact lenses
Cancer (past or current)
None of the above

Family History:*

	Still living?	Cause of death	Major health issues
Mother
Father
Siblings
Maternal Grandmother
Maternal Grandfather
Paternal Grandfather
Paternal Grandmother

Digestion & Elimination:
Typical breakfast:*
Typical lunch:*
Typical dinner:*
Snacks:*
Water intake (glasses/day):*
Caffeine: *
Do you use tobacco?*
If so, quantity:
Alcohol?*
If so, quantity/ounces per day:
Marijuana?*
If so, quantity:
Other:
Have you been under treatment for substance use?*
What is the worst item in your diet?*
What foods are your weakness?*
Are you subject to binge eating?*
If so, what foods?*
Do you experience bloating/gas/burps after eating?*
What foods trigger this?*
How often are your bowel movements?*
Do your stools:*
Constipation?*
Blood in stool?*
Mucus in stool?*
Pain when stooling?*
Other concerns:
Emotional & Spiritual
What is your opinion of yourself?*
If possible, please describe the most negative emotion you experience:*
When and where do you most often feel this emotion?*
Do you pray or have a spiritual practice?*

Please rate yourself:*

	On a scale of 1-10 (1 being lesser, 10 the greater)
Trust
Hope
Charity
Generosity
Sense of humor
Sense of fun
Fear
Grief

What are hobbies/activities that provide your with a sense of pleasure and accomplishment?*
Describe your exercise routine (type/frequency):*
What changes would you like to achieve in 6 months?*
One year?*
Method of contraception (select):*
Length of time using method (Write 'N/A' if not applicable):*
Reproductive Health History

Female Anatomy
Last Pap smear:*
Results (if known):
Are you under treatment for Infertility?*
Describe the current treatment to date (IUI, IVF, etc.):*
Gynecologic provider:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Menstrual History Review and check as indicated:
Age of Menses:*
What was this like for you?*
Last menstrual period:*
Length of menses:*
Are you trying to conceive?*

YesNo
Possibility of pregnancy?*

Type a question*

	Past	Present	None
Painful periods
Heaviness in pelvis prior to menses
Excessive bleeding pads per hour
Dizziness
Water retention
Endometriosis
Uterine or cervical polyps
Vaginal infection(s)
Bladder infections(s)
Painful intercourse
Episodes of amenorrhea
Irregular cycles (early/late)
Dark, thick blood
Headache/migraine with menses
Bloating
Painful ovulation
Failure to ovulate
Fibroids
Uterine infection(s)
Cysts
Urinary incontinence
Vaginal dryness

Pregnancy history:*

	Yes/No	Number (if applicable)	None/Not Applicable
Pregnancies
Births
Premature births
Complications
Miscarriages
Terminations
Spotting during pregnancy
Weak newborns at birth
Incompetent cervix

Briefly describe your experience with:*

	Write experience here
Pregnancy
Labor
Birthing
Post-partum

Maternal family history (select all that apply):*

InfertilityFibroidsEndometriosisPMSMenopauseCancerMenstrual problemsOtherUnknownNone/Not Applicable
Other:
Medications your mother took when she was pregnant with you (if any/known):
Your birth trauma (if known):
Rate your interest in sex:*
Do you have or ever had difficulty experiencing orgasms?
Do you have any history of the following:*

RapeTraumaIncestOtherNone/Not Applicable
Other:
Did you undergo counseling for this? (Write N/A if not applicable)*
What was this like for you?*
Please feel free to share any additional information:
Menopause (write N/A if not applicable)
Age symptoms began:*
Are they getting*
Are you on/or ever been on hormone replacement therapy?*
If so, how long?*
Name and dose:*
Reason for stopping:*
Age of mother at menopause (if known):
Concerns/experience:*
Check the following symptoms that apply to you:*

Hot flashesVaginal dischargeSpottingDecreased libidoInsomniaDry vaginaFloodingDisturbed sleep patternFatigueDepressionIrregular mensesMemory lossAnxietyPainful intercourseMood swingsIrritabilityIncreased libidoNone of the above/Not applicable
Reproductive Health History

Male Anatomy

Please check the symptoms below that apply:*

	Past	Present	None/Not Applicable
Painful urination
Urinary incontinence or dribbling
Weak or interrupted urine flow
Pain or burning with urination
Nocturnal urination?
Pain in lower back, especially after intercourse
Pain or discomfort in penis, testicles, and/or rectum
Frequent bladder or kidney infections
Urinary retention
Difficult starting or holding urine stream
Blood or pus in urine
Pelvic pressure
Insatiable sex drive
Pain or discomfort between the scrotum and testicles
Pain or discomfort in inner thighs
Difficulty in obtaining or maintaining erections
Painful ejaculation

Write N/A for anything below that is not applicable or unknown
Results of PSA (prostate specific antigen) test if known:*
Date done:*
Results of sperm count (if applicable and known):*
Date done:*
Family history of prostate disease?*
If yes, what type?*
Relationship:*
Family history of cancer?*
If yes, what type?*
Relationship:*
Sexually transmitted disease/infection?*
Type, if known:*
Rate your interest in sex:*
Do you have any history of the following:*

RapeTraumaIncestNone of the above
If so, when?*
Did you undergo counseling for this?*

YesNo
What was this like for you?*
Additional information you feel important your practitioner should know that is not mentioned here:*

CLIENT AGREEMENT
I, First Name* Last Name* give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.

I understand that, according to OSHA, massage and bodywork represents a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk.

I also understand:
1. That massage therapy and/or acupuncture:
- is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow; and
- is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.
2. That the massage therapists and/or acupuncturists:
- do not diagnose illness, disease or any other physical or mental disorder;
- do not prescribe medical treatment or pharmaceuticals; and
- do not perform any spinal manipulations.
3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.

If I need to reschedule due to illness or Covid exposure, I agree to contact The Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, cancelled, or rescheduled with less than 24 hours notice.

I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
Signature*

Clear
Date*

MonthDayYear
Date

Welcome! Thank you for choosing The Teal Center. Please READ and INITIAL each of the following:
POLICIES
* Appointments missed, cancelled or rescheduled with less than 24 hours notice will be charged 50% of the session fee. To avoid being charged for a missed appointment, we invite you to send a friend or family member in your place. Also, if we can fill appointments that are missed, cancelled or rescheduled with less than 24 hours notice the client will not be charged. It is your responsibility to remember your appointments. Confirmation emails are sent 48 hours prior to the scheduled appointment.
blanks* The Teal Center and its practitioners abide by the ethical standards of practice by their respective certification boards (NCBTMB and NCCAOM). All shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, therapists are to terminate the session; payment will be made in full by the client and Center reserves the right to prohibit the client from returning to The Teal Center.
blanks* If you have a cold or other contagious illness, please call us before your so we can check with your therapist to see if it is appropriate for you to come in.
blanks* In order to preserve a peaceful environment, we ask that you silence your cell phones while at The Teal Center.
blanks* Tips are appreciated but never expected. If you wish to leave a gratuity, we ask that you do so in cash or by check made directly to the therapist. Gratuity is also made possible via the Venmo app for some therapists.
blanks* If you move or change numbers, it is your responsibility to inform us. This is important information so we can reach you in case of any emergency or any necessary and unforeseen scheduling changes.
blanks* The Teal Center does not submit insurance claims. We are happy to provide you with medical receipts, any treatment notes and payment history for your personal records. We will communicate directly with your insurer at their request only.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Confidential MALE Intake Form

CLIENT AGREEMENT

Welcome! Thank you for choosing The Teal Center. Please READ and INITIAL each of the following:

POLICIES