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Ideal Protein
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Massage Therapy
Ideal Protein
Meet the Team
Contact Us
Call Today: 407-542-8754
Intake Form
Absolute Health and Wellness Intake Form
Your Information
Your Name
(Required)
First
Last
Your Address
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Street Address
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City
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Referred by
Today's Date
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Date of Birth
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Preferred Method of Contact
Email
Phone
Your Email Address
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Phone
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Alternate Phone
Referring Physician
Physician Phone
Date Of Most Recent Physician Visit
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Next Scheduled Visit
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Symptoms/Conditions
Reason for your visit today
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What activities improve/relieve symptoms?
What activities aggravate/worsen symptoms?
Is the condition related to
Worker's Comp
Auto Accident
N/A
Have you previously received treatment for this condition? (Select All That Apply)
N/A
Physical Therapy
Massage Therapy
Chiropractic
Pain Medication
Other
Other
Are you currently pregnant? If yes, how many weeks?
ObGyn
Please list any current medications and/or nutritional supplements you are taking
Please list ALL fractures/ car accidents/ surgical operations with dates
Please select all conditions that apply
Allergies
Angina/Chest Pain
Anxiety
Arthritis/ Osteoarthritis
Asthma/ Breathing Difficulties
Back Pain
Cancer
Chronic Fatigue
C-section/Hysterectomy
Depression
Defibrillator
Diabetes
Digestive Disorders
Edema/Swelling
Fibromyalgia
Fracture
Headaches
Heart Arrhythmia
Heart Attack
Heart Disease
Hepatitis
Herniated Disk
Hernias
High Blood Pressure
Hip Pain
HIV
Joint Pain
Joint Replacement
Low Blood Pressure
Multiple Sclerosis
Neck Pain
Numbness
Overuse Injury
Pacemaker
Parkinson Disease
Poor Circulation
Recent Surgery
Recent Injury
Rheumatoid Arthritis
Sciatic Pain
Seizures
Skin Disorders
Stress
Stroke
Thyroid Disease
TMJ Pain
Vertigo/Dizziness
Varicose Veins
Hold down the control key for Windows or the command key for Mac to select more options
Are you currently under a doctor’s care for any condition not listed above? If yes, explain
Please read and check the following
(Required)
I understand that this massage session is for therapeutic, relaxation, or stress reduction purposes only, and that NO claim to medical diagnosis or treatment is inferred or implied. Any information provided is for educational purposes only.
SPECIAL NOTE for Insulin Dependent Diabetics receiving Cranial Release Technique: I understand that I MUST and WILL monitor my blood sugar levels for at least the next 72 hours prior to every scheduled injection and/or oral medical ingestion.
I must communicate to my therapist any aggravation, injury or change in physical condition before each session.
It is understood that any illicit or suggestive remarks or advances made will result in immediate termination of the session.
I release the therapist, Maureen Shaw, from any liability for pre-existing conditions or any consequential changes that arise subsequent to this or future treatments.
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Signature
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