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Basic Information Form
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Jeff Odnert
Jordan Delagrange
Dong Ji
Dr. Erica Chao
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Begin Your Healing
Massage Initial Intake
________________________________________________
What are your health concerns and goals?
Allergies:
Vitamins/Supplements and reason for taking:
Medications and reason for taking:
Hospitalizations:
Do you have a pacemaker?
Yes
No
Are you currently Pregnant or attempting to become Pregnant?
Yes
No
Do you suffer from any chronic pain? If yes, Please describe this pain.
Is there anything that aggravates or alleviates your discomfort?
Check all that apply to you:
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness/Tingling
Sprains or Strains
Sweats easily
Hot or Cold easily
I have answered truthfully and to the best of my knowledge
Submit and Sign Consent Form
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