New Patient Intake Form BASIC INFO Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country EMERGENCY CONTACT INFO Emergency Contact Name * First Name Last Name Relationship Emergency Contact Phone Number * (###) ### #### BASIC TREATMENT QUESTIONS Do you have any physical pain? (required) If so, please indicate location of pain and level of pain (scale of 1-10) (required) Do you have any emotional pain? (required) If so, please indicate level of pain (scale of 1-10) (required) What is your stress level? Scale of 1-10 Are you pregnant? (required) Yes No ENERGY HEALING If you are not receiving energy healing, you may skip this section. Have you ever had Reiki or Energy Healing before? Yes No If so, when? With who? For what? Do you feel energy? Yes No Maybe/Sometimes AMPCOIL If you will not be receiving AmpCoil treatment, you may skip this section. Are you on any heart medications or blood thinners? Yes No Do you suffer from seizers? Yes No Do you have a pacemaker, defibrillator or any electrical implants? Yes No Do you have any medical conditions that may be affected by magnetic waves? Yes No Please notes: If you are using the Amp Coil, it is your job to let us know if you have any medical issues that may interfere with the coil or interfere with your health. Please initial here that you have read this. RAINDROP THERAPY If you are not receiving Raindrop Therapy, you may skip this section. Do you have any back issues? Yes No If so, please explain MASSAGE If you are not receiving a massage, you may skip this section. Have you received massage or bodywork before? Yes No What types of bodywork or massage have you received? Frequency? What are your preferred types of massage? Why are you seeking a massage? Please describe any relevant injuries or health conditions. Describe any possible complications or medications you are on that we should be aware of. What are your expected outcomes? functional improvement, symptom relief, wellness, etc. What are your typical daily activities? Affected by condition? What's your occupation? Affected by condition? Are you seeking insurance reimbursement? No Yes, car collision/personal injury Yes, on-the-job injury Yes, private insurance Do you have a physician referral with a diagnosis code? ESSENTIAL OILS May we use essential oils during your treatment? Yes No Maybe If you have any allergies to essential oils, please list them here. If you have any sensitivity to smells (i.e. sage, lavender), please list them here. ADDITIONAL INFO Is there anything else you'd like us to know before your appointment? How did you hear about us? Online Search Printed Materials Friend (please let us know who so we can thank them) Other (please specify below) Please Explain Search query, name of referral, etc. Thank you for completing this intake form. If you have not already done so, please read our appointment policies now.
