For: Assigned male at birth

Date of Initial Visit: ________________________________________________________________________________________

Name: ______________________________________________________________________________________________________

Preferred Pronoun: ________________________________________________________________________________________

DOB: ________________________________________________________________________________________________________

Age: _________________________________________________________________________________________________________

Occupation: ________________________________________________________________________________________________

Marital/Relationship Status: _____________________________________________________________________________

*Confidentiality of medical and personal information obtained during the course of the therapist’s work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release form from their client before taking any information about them. You can obtain a copy of this form you signed (upon request) and the therapist maintains a copy for their records.


I understand that this modality is not a replacement for medical care. The therapist does not diagnose medical illness, disease, or other physical or mental conditions. As such, the therapist does not prescribe medical treatment of pharmaceuticals, nor does she preform spinal manipulations. The therapist may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist updated on my health.

I, (name) __________________________________________ give my permission, for my therapist, to take notes including health history, medical, and/or personal information I choose to disclose to her. I understand this information may be used in case studies of this technique for the purpose of statistical data collection only. All relevant identifying information will not be disclosed, such as name, address, date of birth.

Client Signature: ________________________________________________________ Date:____________________________

Therapist Signature: ___________________________________________________ Date: ____________________________


*Consider this intake form as a step in your healing.

*Only answer what you can, what is relevant to you, and/or what you are comfortable with.


Primary reason for visit:__________________________________________________________________________________

When did you first notice it? _____________________________________________________________________________

What brought it on?________________________________________________________________________________________

Describe any stressors occurring at the time: ___________________________________________________________

What activities provide relief? ___________________________________________________________________________

Is this condition getting worse? ™ Yes ™ No What makes it worse? _______________________________________

Interferes with ™ work ™ sleep ™ recreation __________________________________________________________

Have you had massage therapy before? ™Yes ™No What type? ___________________________________________


Still living? Cause of death/age of & Major health issues

Mother Yes ™ No ________________________________________________________________________

Father Yes ™ No ________________________________________________________________________

Sibling(s) ™ Yes ™ No ________________________________________________________________________

Maternal Grandmother Yes ™ No ________________________________________________________________________

Maternal Grandfather ™ Yes ™ No ________________________________________________________________________

Paternal Grandmother ™ Yes ™ No ________________________________________________________________________

Paternal Grandfather ™ Yes ™ No ________________________________________________________________________


Are you currently under the care of another health care provider(s)? ™ Yes ™ No

Reason(s):______________________________Name(s) of practitioner: ________________________________________

Address: ___________________________________ Phone: ___________________ E-mail: ___________________________

Current medications and/or supplements/remedies: _________________________________________________

Allergies (specify allergen + reaction): __________________________________________________________________

Surgical History (year + type) and/or recent procedures: _____________________________________________

Check the following symptoms that apply to you:

Past Present Past Present

Headaches + type ™ Numbness in feet or legs while standing ™

Asthma ™ ™ Sore heels when walking ™ ™

Cold hands or feet ™ ™ Anxiety ™

Swollen ankles ™ ™ Depression ™ ™

Sinus conditions, frequent colds ™ ™ Sleep disturbance ™ ™

Seizures ™ ™ Fainting spells ™ ™

Low back pain ™ ™ Muscular tension + location ™

Skin disorders + type ™ ™ Varicose veins, hemorrhoids + location ™ ™

Sciatica ™ ™ Herniated/bulging discs ™ ™

Painful, swollen joints ™ ™ Artificial, missing limbs ™

High or low blood pressure ™ ™ Contact lenses ™ ™

Dentures, partials ™ ™ Cancer +type ™ ™

Other (not mentioned above):____________________________________________________________________________

Surgical history + recent procedures: ___________________________________________________________________

Hospitalizations: __________________________________________________________________________________________

Accidents or traumas: _____________________________________________________________________________________

Falls/injuries to sacrum/head/tailbone (describe): ___________________________________________________



Check the following symptoms that apply to you:

Past Present Past Present

Painful urination Difficulty starting or holding urine stream ™

Urinary incontinence or dribbling Blood or pus in urine ™ ™ Weak or interrupted urine flow Pelvic pressure ™

Pain or burning with urination Instable sex drive ™ ™ Nocturnal urination, how often? Pain/discomfort between scrotum+testicles ™ ™ Pain in lower back, esp. after intercourse Pain/discomfort in inner thighs ™Rt ™Lft ™Both™ ™ Pain/discomfort in ™ penis,testicles,rectumDifficulty in ™obtaining ™maintaining erection ™ ™ Frequent bladder or kidney infections, when?Urinary retention ™ ™ Painful ejaculation ™ ™

Results of PSA (prostate specific antigen) test, if known: ____________________Date done: _____________

Results of sperm count, if applicable + known: ________________________________ Date done: ___________

Family history of prostate disease? Yes ™ No Relationship: _______________

Family History of cancer? ™ Yes ™ No Relationship: _______________

Sexually transmitted disease? ™ Yes ™ No Type, if known: _______________

Rate you interest in Sex: ™ High ™ Moderate ™ Low ™ None

Do you have history of: rape trauma incest Did you undergo counseling for this? ™Yes ™ No

Additional information: ___________________________________________________________________________________


Glasses of water/day: ___________________Cups of caffeine/day:__________________________________________

Tobacco quantity/day __________________ Marijuana quantity/day _______ Other: ______________________

Have you been under treatment for substance abuse? ™ Yes ™ No

Are you subject to binge eating? ™ Yes ™ No What foods? _________________________________________________

Do you experience bloating/gas/burps after eating? ™ Yes ™ No What foods trigger this? _____________

How often are your bowel movements? _________________________________________________________________

Constipation? ™ Yes ™ No

Blood in stool? Yes ™ No

Mucus in stool? ™ Yes ™ No

Pain when stooling? Yes ™ No

Other concerns: ____________________________________________________________________________________________


Which the most negative emotion you experience: _____________________________________________________

When do you most often feel this emotion? _____________________________________________________________

What hobbies/activities provide you with a sense of accomplishment? ______________________________

Describe your exercise routine (type, frequency): ______________________________________________________

Do you pray or have a spiritual practice? ™ Yes ™ No