Intake Form | RootSpace Wellness, LLC

Welcome to RootSpace Wellness!

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Client Intake Form

New Client/Patient’s Registration, Health History and Global Pain Scale (GPS) Rating.

Medical Records Request

Use the “Request for Medical Records Form” for individuals to obtain their health information directly from their Primary Care Physician.

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Health Update Form

For returning Client/Patient’s providing new health information. Start Search.

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Treatment Plan

Help your clients by creating a treatment plan with specific goals in mind.

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HIPAA FORM

Medical Release Form Your privacy is our policy

S.O.A.P. Notes

S.O.A.P. Notes help to keep your client’s massage history in order and on track.

Initial Client Intake Form

Massage Therapist & Lic# * Massage Therapist & Lic#

Date

Patient Information

Client Name *

Client Name

First

Last

Birth Month *

Birth Day *

Birth Year *

Employer *

Job Title/Position

Best Phone Number *

Gender

Are you pregnant?

YES

Declined to Answer

Your Home Address *

Your Home Address

City

State/Province

Zip/Postal

Country

Your Work Address

City

State/Province

Zip/Postal

Country

Emergency Contact *

Emergency Contact

First

Last

Emergency Phone Number *

Relationship *

Primary Physician Practice/Name

Doctor Phone Number

Any Medications *

YES

Any Surgeries *

YES

Any Allergies *

YES

Please List All Medications

Please List All Surgeries *

Please List All Allergies

History of Pathology

Rate Your Pain Now? (1 - None / 10 - High Pain) *

How often *

Constant

On & Off

When resting

With activity

OtherOther

When does it feel worse? *

Morning

Afternoon

Evening

While Sleeping

List areas of discomfort or pain, right now? *

Neck

Shoulders

Traps

Deltoids

Upper Arm

Forearm

Hand

Chest

Upper Back

Mid-Back

Lower Back

Stomach

Waist

Hips

Groine

Thighs

Quads

Shens

Calfs

Ankle

Top of Foot

Bottom of Foot

Describe what caused the Pain and Discomfort is for you today? *

Is this a new injury?

Yes

Date of injury

Please describe any accidents, whether they be automobile work related home related or otherwise *

Please list all related treatments you received for the above injuries i.e. operation surgeries, hospitalization visits, etc. *

Please describe anything that increases or decreases the pain *

Symptoms & History

Have you ever received a therapeutic massage for a injury before? *

YES

When and was it effective?

How do you wake up? *

On Back

On Side

On Stomach

Alcohol Usage *

None

1-2 drinks per week

3-4 drinks per week

5-8 drinks per week

OtherOther

Tobacco Usage *

None

1-5 cigarettes per week

6-12 cigarettes per week

13 - 20 cigarettes per week

OtherOther

Coffee Usage *

None

1-2 cups per day

3-4 cups per day

5 - 6 cups per day

OtherOther

What physical duties are required of your occupation? *

What activities and hobbies do you enjoy doing? *

Please check the level of any of the symptoms that apply to you:

Head

Neck

Shoulders

Upper Back

Mid-Back

Lower Back

Hips/Waist

Abdomen

Deltoids

Traps

Thighs

Quads

Shin

Calf

Ankle

Top of Foot

Bottom of Foot

Other

1 - No Pain / 2 - Dull Pain/Pressure / 3 - Numbness/Tingling / 4 - Constant Pain / 5 - Sharp/Shooting Pain

Family History - Please check all that apply: *

Myself

Family

N/A

Kidney Issues *

Myself

Family

N/A

Anemia *

Myself

Family

N/A

Appendicitis *

Myself

Family

N/A

Cancer *

Myself

Family

N/A

Dental Issues *

Myself

Family

N/A

Diabetes *

Myself

Family

N/A

Emphysema *

Myself

Family

N/A

Foot Problems *

Myself

Family

N/A

Heart Disease *

Myself

Family

N/A

a Miscarriage *

Myself

Family

N/A

Multiple Sclerosis *

Myself

Family

N/A

a Stroke *

Myself

Family

N/A

an Ulcer(s) *

Myself

Family

N/A

Consent

1.)  I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.
2.) I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.
3.) I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.
4.) It is my choice to receive therapeutic massage as a form of therapy.
5.) I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

Please Type Full Name to Confirm Consent of the above information *

If you are human, leave this field blank.

Request For Medical Records

Our Request for Medical Records Form allows individuals to obtain their health information efficiently.

Patient's Name *

Patient's Name

Patient's First Name

Patient's Last Name

Patient's Contact Number *

The primary contact number of the patient.

Patient's Email Address

The primary email address of the patient.

Patient's Date Of Birth *

Patient's Address *

Patient's Address

City

State/Province

Zip/Postal

Are these documents being requested by the patient or an authorized requester? *

Patient

Authorized Requester

Authorized Requestor's Information

Requestor's Full Name *

Requestor's Full Name

Requestor's first name

Requestor's last name

Relationship To Patient *

Select your relationship to the patient if you are not the patient.

Requestor's Contact Number *

Requestor's Email Address *

Origin Medical Records Details

Facility Name *

Please enter the name of the facility where the documents are being requested from.

Facility Contact Number *

Facility Email Address *

Patient's Primary Physician Name

Address *

Address

City

State/Province

Zip/Postal

Destination Medical Records Details

Facility Name *

Please enter the name of the facility where the documents will be sent to.

Facility Contact Number *

Facility Email Address *

Address *

Address

City

State/Province

Zip/Postal

Medical Items Being Requested *

Entire Record

Treatment Plans/Updates

Diagnoses

Discharge Summary

Recommendations

Intake Paperwork

Lab Results

Imaging Reports (e.g., X-rays, MRIs)

Surgery Reports

Immunization Records

Progress Notes

Prescription History

Mental Health Evaluations

Physical Therapy Notes

Allergy Records

Consultation Reports

Pathology Reports

Emergency Room Visit Notes

Family Medical History

Kindly choose the medical items that are relevant from the provided list.

Purpose Of Requested Information *

Personal Records

Legal Purpose

Continuity of Care

Insurance Claims

School or Employment

Research or Quality Improvement:

OtherOther

Additional Notes

Delivery Method *

Please select the preferred delivery method.

Date Of Request *

Kindly select the date when this request was made.

Authorization

Authorization Statement *

I, the undersigned, either as the patient or as the authorized representative of the patient, give permission for the patient's medical records to be shared with the specified person or organization. I acknowledge that these records may contain sensitive and confidential health information.

Signature *

Clear

Captcha

If you are human, leave this field blank.

Health Update Form

Please use the "Health Update Form" to gather new and updated information on existing clients/patients.

Please Update All Relevant Information

Has anything in your personal, medical history, family or emergency contact changed, since your last visit? *

YES

What do you want to update? *

Patient Information

Emergency Contact Information

New Medical Information

Family History

Other (Please Specify)

Patient's information

Name *

Name

First

Last

Date of Birth *

Gender *

Phone Number *

Email Address *

Emergency Contact

Emergency Contact Name *

Emergency Contact Name

First

Last

Relationship to Patient *

Emergency Contact Number *

Medical History

Check the symptoms that you' re currently experiencing:

Allergy

Cardiovascular

Chest Pain

Diabetes

Ear / Nose / Throat

Eye

Fever

Gastrointestinal

Genitourinary

Hematological

Lymphatic

Musculoskeletal

Neurological

Psychiatric

Respiratory

Weight Gain

Weight Loss

OtherOther

Are you currently taking any medications? *

YesYes

Do you have any known medical allergies? *

YesYes

Are you currently under medical treatment? *

YesYes

Have you been admitted to hospital or had surgery within the last 2 years? *

Yes

Do you use any kind of tobacco or have you ever used them? *

YesYes

Do you use any kind of illegal drugs or have you ever used them? *

YesYes

How often do you consume alcohol? *

Family History

Check the conditions that apply to you or any member of your immediate family:

Asthma

Cancer

Cardiac Disease

Diabetes

Epilepsy

Hypertension

Lung Problems

Psychiatric Disorder

Seizure Disorder

Stroke

OtherOther

Additional Info

Patient Health History Update

Please write anything you feel would help us to better understand your specific health needs.

Start Over

If you are human, leave this field blank.

Patient Treatment Plan

Patient Name *

First

Last Name *

Last

Areas of Improvement (Check all that apply) *

Neck

Shoulders

Upper Back

Lower Back

Hips

Arms

Legs

Foot/Ankle

OtherOther

Please Describe the Treatment Plan. *

Clients Goals

Therapist Goals

Therapists Name *

First

Follow Up Date *

If you are human, leave this field blank.

S.O.A.P. Notes

Client Full Name *

Client Email Address *

Client Phone Number *

Medical History

Current Complaint *

Current Medications

Photos of the Body - Anterior Image

Maximum file size: 516MB

Body Markings - Anterior (mark areas with an 'X')

Photos of the Body - Posterior Image

Maximum file size: 516MB

Body Markings - Posterior (mark areas with an 'X')

Therapist Comments

SOAP Notes

SUBJECTIVE

OBJECTIVE

ASSESSMENT

MANAGEMENT PLAN

Add Remove

Therapist Name *

Today’s Date

If you are human, leave this field blank.

We want to add you to our list of satisfied customers!

See why having a RootSpace Membership may help you with a better night’s sleep, more satisfaction from relaxation, and pure groundedness!

Schedule a Session

Welcome to RootSpace Wellness!

Client Intake Form

Medical Records Request

Health Update Form

Treatment Plan

HIPAA FORM

S.O.A.P. Notes

Initial Client Intake Form

Patient Information

History of Pathology

Symptoms & History

Consent

Request For Medical Records

Authorized Requestor's Information

Origin Medical Records Details

Destination Medical Records Details

Authorization

Health Update Form

Please Update All Relevant Information

Patient's information

Emergency Contact

Medical History

Family History

Additional Info

Patient Treatment Plan

S.O.A.P. Notes

SOAP Notes

We want to add you to our list of satisfied customers!

See why having a RootSpace Membership may help you with a better night’s sleep, more satisfaction from relaxation, and pure groundedness!

Ready to Experience Real Relief?

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