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 ) 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 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

Pain always in same area(s) Stiffness, cramping Feels better with pressure Pain moves around Hot or Swollen Rest helps Pain related to an injury Area feels cool Movement helps Pain mostly in joints Sharp and stabbing Worse in cold weather Pain mostly in muscle Dull – aching Worse in damp weather Pain limits movement Feels better with cold Numbness or heavy sensation Feels better with heat

Please list any significant physical trauma (auto accidents, injuries, surgeries, work related injury, stress, physical abuse), etc Date ______Describe ______

Date ______Describe ______

Significant Emotional trauma (divorce, deaths, difficult changes)

Date ______Describe ______

Date ______Describe ______

Zen Shiatsu Therapy Intake Form (All information is kept strictly confidential)

Five Element Checklist

Please mark as follows: ( S) = Sometimes Experience ( O) = Often Experience

ST/SP LU/LI __ Appetite – too high, too low __ Chronic cough __ Tiredness __ Shortness of breath __ Loose stools __ Asthma __ Constipation __ Chronic Sinus infections __ Weak voice __ Indigestion/heartburn/reflux __ Dry throat, hoarseness, dry cough __ Bloating/gas after eating __ Daytime sweating __ Belching, Vomiting, nausea, pain __ Nighttime sweating __ Mental fatigue – foggy __ Skin problems, eczema, and psoriasis __ Weak limbs – lack flexibility __ Toothaches __ Undigested food in stool __ A feeling of retention of food in the stomach __ Bleeding gums __ Bruise easily __ Cold Limbs LV/GB __ Tendency to become obsessive __ Pain – general body pain __ Worry too much __ Sighing (do you notice yourself sighing)? __ Depression HT/SI __ Numbness in extremities __ Insomnia, difficulty sleeping __ Tics or tremors __ Heart palpations __ Dizziness __ Anxiety __ Anemia __ Dizziness __ Eyes – blurred, floaters, dry, red? __ Insomnia __ Dry skin/hair – brittle nails __ Dream disturbed sleep __ Stiff neck/ joints – chronic __ Easily startled __ PMS – any related issues __ Blood clots __ Headaches __ Mental confusion __ Diarrhea __ Cold limbs __ Flashes of anger __ Feeling of heaviness in chest __ Bitter taste in mouth __ Pain radiating down left arm __ Uncontrollable laughter or crying __ Spontaneous sweating KI/UB ( , yin, yang jing def.) __ Asthma TH/PC __ Cold limbs __ Excess urination __ Swollen lymphatic glands __ History of Urinary tract infections __ Nervous in social situation __ Incontinence __ Tonsillitis __ Dizziness __ Allergies __ Tinnitus – ringing in ear __ High Blood pressure __ Night sweats __ Low Blood pressure __ Sore or weak back __ Sensitive skin __ Knee – sore or weak __ Rashes __ Edema __ Hives __ Aversion to cold __ Weak bones, teeth ___ Low Libido/ Sexual dysfunction

Zen Shiatsu Therapy Intake Form (All information is kept strictly confidential)

Are you a morning, midday, afternoon, early evening or night person? ______Which season do you love the most? spring, summer, late summer, fall, winter Which season do you dread? spring, summer, late summer, fall, winter What are your favorite colors? ______Which colors are you avoiding now? ______What is your favorite taste? (Circle) sour bitter sweet spicy salty Have you craved any of these tastes this week? If so, which? ______Which sense is the best? (Circle) sight speech taste smell hearing Which sense is most challenged? (Circle) sight speech taste smell hearing

Diet & Lifestyle

Please list all supplements you are currently taking: Type (Brand) Reason Dosage & duration you’ve been taking

Please describe your diet Balanced diet of natural foods & processed foods including; fruits, veggies, meat, dairy, grains. Vegetarian (If yes for how many years) ______ Vegan (If yes for how many years) ______

My diet is…. Heaviest on Meat (meaning red meat more that 3 days a week) Heaviest on Pastas, breads, cereals (circle) whole grain or processed Heaviest on Sweets Heaviest on Salty Snacks

What do you typically eat for Breakfast______Lunch______Dinner______ Coffee ____ cups per day Soda ____per day diet sugared Micro waved food ____ times per week Do you smoke? ____ # of Cigarettes per day Alcohol Light Moderate Heavy

How often do you have a bowel movement? ______

What do you like to do for fun? Hobbies? ______

How often do you get to enjoy them?______

Do you exercise? ______What type?______How often? ______

Zen Shiatsu Therapy Intake Form (All information is kept strictly confidential)

How is your Sleep?

What time do you usually go to sleep?______What time do you usually get up? ______Do you usually get to sleep within 20 minutes of retiring? Yes No Do you often (3x week or more) wake up in the middle of the night? Yes No If so, is urinary urgency the main factor in waking up? Yes No Do you get back to sleep easily? Yes No Do you feel refreshed after a typical night of sleep? Yes No If you awaken in the night, what time is it usually? ______am/pm How many hours of sleep do you typically get? ______hrs. Do you experience any pain at night that wakes you up? ______Do you experience an energy drop at a regular time of day? ______Any additional comments? ______

Please use the area below to add any further thoughts, ideas or information that you believe may be helpful or relevant in any way (even if you aren’t certain).

Zen Shiatsu Therapy Intake Form (All information is kept strictly confidential)

INFORMED CONSENT TO SHIATSU THERAPY

It is my choice to receive shiatsu therapy. I realize that the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm/pain, and improving circulation. I agree to communicate with my practitioner any time I feel like my well-being is being compromised.

I understand and am informed that in the practice of shiatsu there are some possible physical, emotional and mental side effects that may occur. I do not expect the therapist to be able to anticipate and explain all risks and complications. I rely on the therapist to exercise his best judgment during the course of the procedure, which he feels at the time, based upon the facts then known, is in my best interest. I further understand that results are not guaranteed.

I understand that Shiatsu therapists do not diagnose illness, disease, or any physical or mental disorders, nor do they prescribe medical treatment or pharmaceuticals. I acknowledge that shiatsu is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service. I have stated all medical conditions that I am aware of and will update my shiatsu therapist of any changes in my health status.

I have read the above consent. I have had an opportunity to ask questions about its content, and by signing below, I agree to the included procedures. I intend this consent form to cover the entire course of my treatment plan.

TO BE COMPLETED BY PATIENT:

______Print client’s name Signature of Client (or parent/guardian)

______Date signed