Zen Shiatsu Zen Shiatsu Therapy Intake Form

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 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 ( Qi, 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

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