Docstoc

INTAKE

Document Sample
INTAKE Powered By Docstoc
					                               SHORT FORM - HEALTH HISTORY INTAKE


PROVIDER NAME:     MICHAEL W. UGGEN      LICENSE: MA 16912   DATE:

NAME                                                         PHONE

ADDRESS                                          EMERGENCY CONTACT:

CITY/STATE/ZIP:                                              CONTACT #


    1      WHAT ARE YOUR GOALS FOR TODAY'S SESSION?




    2      LIST ANY ILLNESSES, INJURIES OR HEALTH CONCERNS YOU NOW HAVE OR HAVE HAD
           IN THE LAST THREE YEARS.




    3      LIST ANY MEDICATIONS OR PAIN RELIEVERS TAKEN IN THE LAST 48 HOURS




    4      DO YOU NOW HAVE:                      HAVE YOU EVER HAD:
           HIGH OR LOW BLOOD PRESSURE            HEART DISEASE
           INFECTIOUS SKIN CONDITIONS            CANCER
           CONTAGIOUS DISEASE                    LYMPH NODE REMOVAL
           DIABETES                              VARICOSE VEINS
           ARTHRITIS                             BLOOD CLOTS
           SPINAL PROBLEMS                       STROKE
           PREGNANCY                             SCIATICA
           CARPAL TUNNEL SYNDROME                SURGERY


    5      DO YOU WEAR
           CONTACT LENSES                HEARING AIDS        DENTURES

    6      ARE YOU CURRENTLY UNDER THE CARE OF A PHYSICIAN OR OTHER HEALTH CARE
           PROVIDER FOR ANY SPECIFIC CONDITION?

    7      I UNDERSTAND THAT MASSAGE PRACTITIONERS DO NOT DIAGNOSE ILLNESS, DISEASE,
           OR OTHER PHYSICAL OR MENTAL DISORDERS. MASSAGE PRACTITIONERS DO NOT
           PRESCRIBE MEDICAL TREATMENT OR PHARMICEUTICALS. IT HAS BEEN MADE CLEAR
           TO ME THAT MASSAGE 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.

           I HAVE STATED ALL MY KNOWN MEDICAL CONDITIONS AND TAKE IT UPON MYSELF TO
           KEEP THE MASSAGE PRACTITIONER UPDATED ON MY PHYSICAL HEALTH

           IT IS MY CHOICE TO RECEIVE MANUAL THERAPY AND I GIVE MY CONSENT TO RECEIVE
           TREATMENT.


           SIGNATURE                             DATE

				
DOCUMENT INFO