When this form is successfully completed, the page should refresh to show you a “Form successfully submitted” note. Complete this form before your first appointment. Once you are an established client, we have a separate check-in process so you do not have to repeat the same intake form over and over. [If you prefer paper intake, please download and print the form].

Web Site

First Name *

Last Name *

Client Address *

City *

State *

Zip *

Current Health Concern *

Concern Severity *

Mild

Moderate

Severe

Concern Frequency *

Constant

Intermittent

Rare

Concern Symptoms *

Increases with Activity

Decreases with Activity

No Change with Activity

Concern Changes *

Getting Worse

Getting Better

No Change

Treatment Received *

Medications *

Activities Limited by Condition *

Comments

Please see the linked document for our complete privacy policy. Additional HIPAA and practice agreements can be found at www.caringportland.com/clientforms

https://www.juliemaelmt.com/privacy/ *

If someone referred you & it's okay to share their name, put it here so I can thank them

Phone Number *

Alternate Phone Number

Email *

Preferred Contact Method *

Pronouns *

Name (if different from Legal Name)

What are your typical daily activities - work, home, exercise?? *

What substances are you currently taking? (prescription, herbs, supplements, alcohol, recreational, OTC) *

Have you had professional massage before? *

Yes

Yes, but quite a long time ago

What level of pressure do you prefer? *

Don't know

Light

Medium

Hard

What are your current goals for massage? *

Emotional stress scale: 0 is no stress... 10 is extremely stressed *

Physical pain scale: 0 is no pain... 10 is extremely painful *

Insurance Information

MVC or Worker's Comp

If you were in an accident, please provide the following information:

Claim Number

Adjuster’s Name

Adjuster’s Email Address

Adjuster’s Phone Number

Adjuster’s Fax Number

Insurance Agency & Address

Do you have a prescription for Massage?

Yes

Date of Injury (accident)

Please be prepared to bring Medical referral or prescription for message to first appointment. This should include a Diagnosis Code.

Primary Insurance Information

If you seek to use your health insurance, please provide the following information:

Insured person's name (if not yourself)

Insured’s employer

Gender According to Insurance

Marital Status

Birth Date

Primary Insurance Plan Name

Insurance Phone

Group Number

Plan Number

Plan’s Billing Address

Please be prepared to bring your insurance card/ID to first appointment. We may call before your appointment to verify information. Some insurance providers require a prescription or referral for massage.

Message / Comments

Health History

Please provide information for the past five years, including type, approximate dates and treatment

Surgeries *

Major Illnesses *

Injuries *

Health Conditions

Please select any current and previous conditions.

General

general list *

Pain

Numbness

Altered Sensation

Headaches

Fatigue

Sleep Disturbances

Shunts

Plates

Pints / Rods

Transplant

Dizziness

Fainting

Bruise easily

Aching joints

Allergies

Infections

Swelling

Other

Not Applicable

if Other, please describe

Skin Conditions

skin list *

Abrasions/Cuts

Rashes

Other

Not Applicable

if Other, please describe

Muscles and Joints

muscle list *

Arthritis

Osteoporosis

Scoliosis

Fractures

Sprains Strains

Bursitis

Tendonitis

Stiffness

Disk Problems

TMJ

Other

Not Applicable

if Other, please describe

Cardiovascular and Respiratory

cardio list *

Anemia

Angina

Arteriosclerosis

Heart Attack

Asthma

Congestive Heart Failure

Heart Disease

Hypertension

Irregular Heart Beat

Varicose Veins

Blood Clots

Phlebitis

Other

Not Applicable

if Other, please describe

Nervous System

nervous list *

Concussion

Head Injury

Stroke

Anxiety

Depression

Other

Not Applicable

if Other, please describe

Endocrine System

endo list *

Type I Diabetes

Type 2 Diabetes

Thyroid

Gestational Diabetes

Other

Not Applicable

if Other, please describe

Digestion and Elimination

digest list *

Heartburn

Gastric Reflux

Ulcers

Bowel Problems

Gas/Bloating

Urinary Tract Problems

Other

Not Applicable

if Other, please describe

Reproductive System

repro list *

Pregnancy

PMS

Other

Not Applicable

if Other, please describe

Cancer or Tumors

cancer list *

Benign

Malignant

Not Applicable

if history of Cancer or Tumors please describe

I Agree

I understand that the massage/bodywork 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 practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork 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 specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners 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 the session given should be construed as such. Because massage/ bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

https://www.juliemaelmt.com/client-forms *