Zen Shiatsu Therapy Intake Form (All information is kept strictly confidential)
Name ______Date ______
Date of Birth ______/______/______Age______Height______Weight ______
Home Address ______
City:______State______Zip ______
Current Employer______Job Title______
Home Phone (_____)______–______O.K. to leave messages? ( Y / N )
Cell Phone (_____)______–______O.K. to leave messages? ( Y / N ) Text Messaging Available? ( Y / N )
Email______Would you like to be on our mailing list? ( Y / N )
Name of Emergency Contact ______Contact Number (_____)______–______
How did you hear about us ? Search Engine___ Yellow Pages___ Referral ___ Other (Please specify)______
Why have you chosen to have Zen Shiatsu Therapy ?______
Have you had Zen Shiatsu Therapy? ( Y / N ) Massage Therapy? ( Y / N ) What kind?______
When was your last Shiatsu or Massage session? ______
How many sessions have you had? ______How often do you have sessions ?______
Natural Health Practitioners look to the roots of imbalance and which energetic s ystem is showing the most symptoms. Therefore, your careful and thoughtful answers will provide you with a more effective session. Even if you are just looking for a pleasant bodywork session and not concerned with any particular issues, please take the ti me to complete all relevant information. Please ask if you have any questions.
Medical History
Are you currently under the care of a Medical Doctor or other Alternative Health Care Provider? ( Y / N ) Provider Information
Provider Name Phone Type of Treatment
Zen Shiatsu Therapy Intake Form (All information is kept strictly confidential)
Please list all medications you are currently taking: Type (Brand) Reason Dosage & duration you’ve been taking
___ Allergies, sensitivity ___ Digestive complaints ___ Heart problems (specify) (specify)______Food cravings (specify) ______Asthma ______Low Blood Pressure ___ Respiratory problems ___ Feeling of heaviness in body ___ Palpitations ___ Sinus problems ___ Mental fatigue ___ Insomnia, difficulty falling asleep ___ Abnormal skin conditions ___ Varicose veins ___ Dream disturbed sleep ___ Elimination problems ___ Bruise easily ___ Anxiety ___ Hemorrhoids ___ Distention in lower abdomen ___ Crohn’s disease
___ Low back and/or knee pain ___ Swollen lymphatic glands ___ High Blood Pressure ___ Osteoporosis ___ Hypersensitivity ___ Dizziness ___ Urinary problems and/or infections ___ Rashes/ hives ___ Anger /irritability ___ Phobias/ Fears ___ Nervous in social situations ___ Stiff joints ___ Nervous problems ___ Swelling or chilling of extremities ___ Jaundice ___ Ear problems ___ Circulatory problems ___ Sore eyes ___ Wake up many times at night ___ Brittle nails ___ Sexual/reproductive dysfunction ___ Wake up early then fall asleep again
___ Anemia ___ Epilepsy ___ Tendonitis (specify) ___ Arthritis (specify)______Fibromyalgia ______Candida ___ Headaches, migraines ___ Cancer ___ Mental health issue ___ Sprains/strains (specify) ___ Chronic fatigue syndrome (specify)______Diabetes ___ MS ___ Recent injuries(specify) ______
Females : ___ Menstrual Problems (specify eg. cramps) ______
___ Menopause
Zen Shiatsu Therapy Intake Form (All information is kept strictly confidential)
Current Condition
Please rate the following with a circle. 0 = none 10 = the most/highest Pain 0 1 2 3 4 5 6 7 8 9 10 Energy 0 1 2 3 4 5 6 7 8 9 19 Stress 0 1 2 3 4 5 6 7 8 9 10
Main problem(s) you would like help with today ______
______
______
How long ago did the problem(s) begin? – be specific ______
To what extent does the problem(s) interfere with your daily activities? ______
______
Have you ever been given a diagnosis for this problem(s)? If so, what diagnosis and by whom?
______
What kind of treatments have you tried, what has helped?
______
______
Zen Shiatsu Therapy Intake Form (All information is kept strictly confidential)
Please indicate painful or distressed areas & Rate:
1 = Chronic Pain 2 = Acute Pain 3 = Scars
Please check all that apply