"Men's Sexual Health Intake Form - Wave Clinic"

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Men's Sexual Health Intake Form
Name: ____________________________________________________
Date of Birth: _________________
Work/Cell Phone: _____________________________ E-mail:_______________________________________________
Occupation: __________________________________________________________________________________________
Emergency Contact: _______________________________________________Phone: ___________________________
Are you currently under a physicians care for an acute or chronic illness? Y __ N __
If yes, please explain: _________________________________________________________________________
Your health care provider: ____________________________________________________________________
Are you currently taking any prescribed medication or dietary supplements? Y __ N __
If yes, please list: ______________________________________________________________________________
What are you currently experiencing that you would like addressed? Please explain: ________________
_______________________________________________________________________________________________________
How long have you been experiencing these symptoms? ____________________________________________
______________________________________________________________________________________________
___________________________________________________________________
How did you hear about us?
Health Information
Please mark an (X) by all current conditions and (P) for all past
conditions
__ Diabetes
__ Abdominal /digestive problems
__ Pregnancy
__ Fatigue
__ Allergies
__ Rash/fungus
__ Headaches, migraine
__ Anxiety
__ Sinus problems
__ Arthritis/tendonitis
__ Hearing problems
__ Sleep difficulties
__ Asthma or a lung condition
__ Hernia
__ Spinal disorders
__ Athletes foot
__ High blood pressure
__ Sprain/strain
__ Blood clots
__ Jaw pain/TMJ pain
__ Tension/stress
__ Chronic pain
__ Low blood pressure
__ Vision problems
__ Circulatory/heart problems
__ Muscle/bone injuries
__Varicose veins
__ Constipation/diarrhea
__ Muscle/joint pain
__ Other __________________________
__ Depression
__ Numbness/tingling
Elaborate on noted areas above: _________________________________________________________________________________
___________________________________________________________________________________________________________________
Men's Sexual Health Intake Form
Name: ____________________________________________________
Date of Birth: _________________
Work/Cell Phone: _____________________________ E-mail:_______________________________________________
Occupation: __________________________________________________________________________________________
Emergency Contact: _______________________________________________Phone: ___________________________
Are you currently under a physicians care for an acute or chronic illness? Y __ N __
If yes, please explain: _________________________________________________________________________
Your health care provider: ____________________________________________________________________
Are you currently taking any prescribed medication or dietary supplements? Y __ N __
If yes, please list: ______________________________________________________________________________
What are you currently experiencing that you would like addressed? Please explain: ________________
_______________________________________________________________________________________________________
How long have you been experiencing these symptoms? ____________________________________________
______________________________________________________________________________________________
___________________________________________________________________
How did you hear about us?
Health Information
Please mark an (X) by all current conditions and (P) for all past
conditions
__ Diabetes
__ Abdominal /digestive problems
__ Pregnancy
__ Fatigue
__ Allergies
__ Rash/fungus
__ Headaches, migraine
__ Anxiety
__ Sinus problems
__ Arthritis/tendonitis
__ Hearing problems
__ Sleep difficulties
__ Asthma or a lung condition
__ Hernia
__ Spinal disorders
__ Athletes foot
__ High blood pressure
__ Sprain/strain
__ Blood clots
__ Jaw pain/TMJ pain
__ Tension/stress
__ Chronic pain
__ Low blood pressure
__ Vision problems
__ Circulatory/heart problems
__ Muscle/bone injuries
__Varicose veins
__ Constipation/diarrhea
__ Muscle/joint pain
__ Other __________________________
__ Depression
__ Numbness/tingling
Elaborate on noted areas above: _________________________________________________________________________________
___________________________________________________________________________________________________________________
Please list any injuries or surgeries in the pelvic region: _________________________________________________
_________________________________________________________________________________________________________
Please list your stress-reduction activities, exercise and frequency:______________________________________
______________________________________________________________________________________
I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge.
I will inform my health care provider and massage therapist if anything changes in my status. I understand that
massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension, spasm or
pain and to increase circulation. If I experience any pain or discomfort, I will immediately inform my massage
therapist so that the pressure and/or methods can be adjusted to my comfort level. I understand that my massage
therapist does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any
medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and
that I should see my health care provider for those services. If I am unable to attend my scheduled appointment, I will
respect and abide by the set cancellation policies. Sexual advances, request for sexual favors, and other verbal or
physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated. I understand that I
am receiving massage therapy at my own risk. In the event that I become injured either directly or indirectly as a
result, in whole or in part, of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist, their
principals, and agents from all claims and liability whatsoever.
Client Signature: ________________________________________________ Date: _____________
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