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    Welcome Sheet Front

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    api-202404877
    This document collects personal and medical information from a new patient, including their name, contact details, date of birth, gender, occupation, reason for visit, history of injuries, description of any ongoing pain conditions, and prior medical treatment. Preferences for massage pressure and consent for social media engagement are also requested. The summary provides essential intake details to inform the massage therapist about the patient's medical history and treatment needs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd

    Welcome Sheet Front

    Uploaded by

    api-202404877
    975 views1 page
    This document collects personal and medical information from a new patient, including their name, contact details, date of birth, gender, occupation, reason for visit, history of injuries, description of any ongoing pain conditions, and prior medical treatment. Preferences for massage pressure and consent for social media engagement are also requested. The summary provides essential intake details to inform the massage therapist about the patient's medical history and treatment needs.

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    welcome sheet front

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    © Attribution Non-Commercial (BY-NC)

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    This document collects personal and medical information from a new patient, including their name, contact details, date of birth, gender, occupation, reason for visit, history of injuries, description of any ongoing pain conditions, and prior medical treatment. Preferences for massage pressure and consent for social media engagement are also requested. The summary provides essential intake details to inform the massage therapist about the patient's medical history and treatment needs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    975 views1 page

    Welcome Sheet Front

    Uploaded by

    api-202404877
    This document collects personal and medical information from a new patient, including their name, contact details, date of birth, gender, occupation, reason for visit, history of injuries, description of any ongoing pain conditions, and prior medical treatment. Preferences for massage pressure and consent for social media engagement are also requested. The summary provides essential intake details to inform the massage therapist about the patient's medical history and treatment needs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    About you

    Todays Date _____/______/______


    Patient Name: ___________________________________ What you prefer to be called ________________
    LAST

    FIRST

    MI

    Birth date: ______/______/_____


    Age: ________
    Mailing Address:____________________________________________

    Male

    Female

    ___________________________________________________________
    City

    State

    Zip

    Home Phone #: ______________________Work Phone #: ____________________ Ext: _________


    Other Phone #: _____________________________
    Email: ____________________________________
    What is your occupation? _________________________________
    How did you hear about us? _______________________________
    Have you been treated by a Massage Therapist before? Yes No
    If so, who? _________________________________________
    What kinds of pressure do you prefer?

    Light

    Medium Firm

    Do you have a Facebook page? ___Yes ___No


    Can we send you a request to like our page? ___Yes ___No FB Name: _________________________
    Note: If you make a comment on our page about your treatment, we will send you a coupon for your
    next session. Thank you for helping us grow.
    Reason for visit
    The reason for this visit is a result of (please circle):
    work injury, sports, auto, trauma, chronic pain, relaxation, monthly wellness, birthday
    In the past five years have you had any injuries?
    ______________________________________________________________________________
    ______________________________________________________________________________
    If you have any ongoing pain in the body that is reoccurring, please describe the pain and its
    location:_______________________________________________________________________
    ______________________________________________________________________________
    When did the condition begin? ____/____/____
    Is this condition getting worse? Yes No Constant Comes and goes
    Is this condition interfering with your (please circle) work, sleep, or daily routine
    If so, please explain: ____________________________________________________________
    Have you been treated by a Medical Physician for this condition? Yes No
    If so, where? ___________________________________________________________________

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