blockchiropracticcenter.com

New Patient Intake Form

Therapeutic Massage
Personal Information:
Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
DOB

MonthDayYear
Date
Occupation
Emergency contact
Phone Number
Please enter a valid phone number.
As of Jan 1, 2021 we are requiring that ALL appointments are held with a credit card number.

Please find attached a PDF of the new patient paperwork. Please print them and either scan it back to us or bring it with you at your appointment. If you cannot print it please arrive 20 minutes early to complete the paperwork in the office.

It is imperative that you complete it prior to your appointment so as to not cut into your appointment time.

Please bring your license or photo ID card, your health insurance card(s), and the completed new patient paperwork with you to your first visit.

Please feel free to give us a call if you have any additional questions (301) 476-7575. We are located at 3919 National Drive, Suite 110, Burtonsville, MD 20866.

We look forward to meeting you!

We do require a 48-hour notice for all cancellations and you will be charged a $70 cancellation fee if you do NOT cancel within 48-hours of your scheduled appointment.

The following information will be used to help plan safe and effective massage sessions.

Please answer the questions to the best of your knowledge.
Date of initial visit

MonthDayYear
Date
1. Have you had a professional massage before?

YesNo
If yes, how often
2. Do you have any difficulty lying on your front, back or side?

YesNo
If yes, please explain
3. Do you have any allergies to oils, lotions or ointments?

YesNo
If yes, please explain
4. Do you have sensitive skin?

YesNo
5.Are you wearing contact lenses, dentures or hearing aid?

YesNo
If yes, please describe
6. Do you sit for long hours at w workstation, computer or while driving?

YesNo
If yes, please describe
7. Do you perform any repetitive movement in your work, sports or hobby?

YesNo
If yes, please describe
8. Do you experience stress in your work, family or other aspects of life?

YesNo
If yes, how do you think it has affected your health?
Muscle tensionAnxietyInsomniaOther
9. Is there a particular area of the body where you are experiencing tension, stiffness, pain or discomfort?

YesNo
If yes, please identify
10. Do you have any particular goals in mind for this session?

YesNo
If yes, please explain
Medical History:
In order to plan a safe and effective massage session I will need some general information

about your medical history.
11. Are you currently under medical supervision?

YesNo
If yes, please explain
12. Do you see a chiropractor?

YesNo
If yes, please list
13. Are you currently taking any medication?

YesNo
If yes, please list
14. Please check any conditions listed below that apply to you:

Contagious skin conditionPhlebitisOpen sores or woundsDeep vein thrombosis/blood clotsEasy bruisingJoint disorder/rheumatoid arthritisOsteoarthritis/tendonitisRecent injury or accidentOsteoporosisRecent fracturesEpilepsyRecent surgeryHeadaches/migrainesArtificial jointCancerSprains/strainsDiabetesCurrent feverDecreased sensationSwollen glandsBack/neck problemsAllergies/sensitivityFibromyalgiaHeart conditionTMJHigh or low blood pressureCarpal tunnel syndromeCirculatory disorderTennis elbowVaricose veinsAtherosclerosisPregnant
If Pregnant, how far along?
Please explain any conditions that you have marked above:
15. If there is anything else about your health history that might be useful for your massage practitioner to know ahead of time?
Draping will be used during the session- on/y the area being worked on will be uncovered. Clients under the age of 17, must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided dy parent or legal guardian for any client under the age of 17.
I, (print name) understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the massage therapist so that the pressure and or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialists for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of this session should be construed as such. Since massage should not be performed under certain medical conditions, I affirm that I have stated all known medical conditions and have answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so.
Signature of client

Clear
Date

MonthDayYear
Date
Signature of Massage Therapist

Clear
Date

MonthDayYear
Date
Should be Empty:

New Patient Intake Form

Personal Information:

Medical History: