Intake

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Rapid Tx

Intake Form

Please fill out and submit before your appointment

*Required Field

Todays Date

Name

Email

Phone*

Date of Birth

Occupation

Emergency Contact

How did you hear about Rapid Tx

Are you taking any medications?

Yes

No

If yes, please list

Are you pregnant?

Yes

No

Are you currently involved in a lawsuit for a personal injury claim? (Ie: WCB, isurance claim, etc) *

Yes

No

Please check all that apply

Areas of swelling

Auto immune disorder

Bleeding disorders

Blood clots

Bruise easily

Bursitis

Cancer

Contagious condition

Diabetes

Fibromyalgia

Headaches/migraines

Heart condition

Kidney disease

Multiple sclerosis

Neurological disorder

Numbness or tingling

Osteoarthritis

Osteoporosis

Phlebitis

Sciatica

Seizures

Stroke

TMJ

Varicose veins

Vertigo/dizziness

None of the above

Please list any injuries or surgeries:

Chief complaint for todays treatment:

Upper back/neck

Lower back/hips

Headaches/migraines

Arms

Legs

Feet

Other

Do you suffer with chronic pain?

Yes

No

What makes it better?

What makes it worse?

By clicking submit, I am aware of the benefits and risks of Massage Therapy/Rapid NFR and I have completed ths form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

Thank you, I look forward to meeting you!

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