Client Intake Form

Please fill out the following form to help us understand your physical condition.

A.  Patient Information

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B.  Emergency Information

Contact information (in case of an emergency):

C.  Medications

D.  Cardiovascular Health

(Please check all that apply)

I am currenly taking:
Bruising
Blood Clots
Raynaud's
High Blood Pressure
Medicated
Asthma
Medicated
Cholesterol
Medicated
Stroke
CVA
TIA
Cardiac Conditions
Heart Surgery
Pacemaker
Neuropathy
Medicated
I have

E.  Diabetes Mellitus Health

Diabetic Type
Medicated

F.  Allergies

(Please check all that apply)

I am allergic to

Allergic to the following medications

Allergic to the following foods

G.  Skin Health

Broken Skin
Skin Cancer

Please answer if you had or have:

Warts
Poison Ivy
Atopic Dematitis
Impetigo
Eczema
Psoriasis
Keratosis pilaris
Actinic keratosis
Calluses
Corns
Athlete's foot (tinea pedis)
Foot odor

H.  Nail Health

Ingrown Toenail(s)
Onychomycosis (Nail Fungus)
Discolored nail(s)
Detached nail(s)
Bruised nail(s)
Thick nail(s)
Thin nail(s)
Affected / Problematic Fingernail(s)

I.  Joint/Skeletal Health

(Please check all that apply)

I have
Neuroma(s)
Disc Problems
Hip Problems
Ankle Problems
Elbow Problems
Knee Problems
Foot/Toe bone Problems
Shoulder Problems
Other Joint Problems

J.  Surgeries

Foot Surgery
Hip Surgery
Knee Surgery
Shoulder Surgery
Hand Surgery

K.  Other Diseases / Recent Injuries

Thyroid Problems
Bone Disease
Arthritis
Rheumatoid arthritis
Epilepsy
Lupus
HIV
Other
Recent Injuries

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