HIS Steam Confidential Client Intake Form

Name (required)

Date of Initial Visit

Address (required)

City (required)

State (required)

Zip code (required)

Home Phone (required)

Work Phone

Email (required)

Date of Birth (required)

Age

Occupation

Marital Status

Referred By

Family History of Prostrate Disease (required):
Type:
Family Member:

Family History of Cancer (required):
Type:
Family Member:

History of Sexually Transmitted Disease (required):
When:
Type:

Rate your interest in sex

Do you have or ever had difficulty experiencing orgasms?

Check all that apply
Urinary SymptomsPainful UrinationBladder/Kidney InfectionsFrequent UrinationNocturnal Urination / Frequency

Changes in Urinary Stream (Describe flow, stream, strength of stream)

When did you first notice these symptoms

Are they getting any worse (Describe)

Erectile Function (Describe difficulty in obtaining an erection, maintaining an erection, painful ejaculation)

When did you first notice these symptoms

Are they getting any worse (Describe)

Current Medications or Supplements

Results of PSA (Prostrate Specific Antigen) Test if Known

Date Done

I UNDERSTAND THAT PAYMENT IS DUE AT THE TIME OF MAKING AN APPOINTMENT FOR TREATMENT. I AGREE TO GIVE AT LEAST 48 HOURS NOTICE OF CANCELLATION OF APPOINTMENT OTHERWISE I WILL LOSE MY PAID TREATMENT FEE IN FULL AND BE REQUIRED TO PAY AGAIN FOR ANY NEW APPOINTMENT. I UNDERSTAND THE TREATMENT HERE IS UNOT A REPLACEMENT FOR MEDICAL CARE. I UNDERSTAND THE THERAPIST/PRACTITIONER DOES NOT DIAGNOSE MEDICAL ILLNESS, DISEASE OR ANY OTHER PHYSICAL OR MENTAL CONDITIONS (UNLESS SPECIFIED UNDER HIS/HER PROFESSIONAL SCOPE OF PRACTICE) AS SUCH, THE THERAPIST/PRACTITIONER DOES NOT PRESCRIBE MEDICAL TREATMENT OF PHARMACEUTICALS, NOR DOE HE/SHE PERFORM ANY SPINAL MANIPULATIONS (UNLESS SPECIFIED UNDER HIS/HER PROFESSIONAL SCOPE OF PRACTICE) I UNDERSTAND THAT THE TREATMENT IS NOT A SUBSTITUTE OF MEDICAL TREATMENTS AND/OR DIAGNOSIS AND IT IS RECOMMENDED THAT I SEE A QUALIFIED PROFESSIONAL FOR ANY PHYSICAL OR MENTAL CONDITIONS THAT I MAY HAVE. I HAVE STATED ALL MY KNOWN CONDITIONS AND TAKE IT UPON MYSELF TO KEEP THE THERAPIST/PRACTITIONER UPDATED ON MY HEALTH.

I GIVE MY PERMISSION FOR MY THERAPIST/PRACTITIONER TO TAKE NOTES ABOUT ME, INCLUDING HEALTH HISTORY, MEDICAL, AND/OR PERSONAL INFORMATION I CHOOSE TO DISCLOSE TO HIM/HER. I ALSO UNDERSTAND THAT THIS INFORMATION WILL ANONYMOUSLY BE USED FOR THE B.I.M HEALTH & FITNESS STUDIO, LLC. FOR STATISTICAL PURPOSES, AND THAT MY PRACTITIONER MAY USE THIS INFORMATION TO PROVIDE ME WITH A SUMMARY FOR MY OWN PERSONAL USE.

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