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Health Information
Medications
Allergies
1. Areas of discomfort/pain
2. Onset of discomfort/pain
3. Rate of Pain
Very Little
1
2
3
4
Very Painful
5
1 is Very Little, 5 is Very Painful
4. Frequency
Constant
Off/On
At Rest
With Activity
Other
5. At what time of day is the pain at its worse?
Morning
Afternoon
Evening
During Sleep
Other
6. Have you ever injured this area before?
7. Have you ever been in an accident (automobile, work, falls, etc.) ?
8. List all related treatments received for this injury
9. Have you ever received therapeutic massage for a specific problem or injury?
10. Is there anything you do that creates, increases or decreases pain?
11. What are the physical duties required of your occupation?
12. Are you currently seeing any other healthcare professional?
Please check any symptoms that apply:
Head Symptoms
Temples
Forehead
Top of head
In the eyes
Entire head
Base of skull
Dizziness
Fainting
Light-headedness
Pain in ears
Ringing in ears
Other
Neck Symptoms
Stiffness
Pain at neck shoulder junction
Pain when turning head
Pain with side to side movements
Neck feels out of place
Muscle spasm in neck
Gliding/Grating sound with neck movement
Diagnosed bone spurs
Diagnosed disc herniation
Other
Shoulders Symptoms
Pain in shoulder
Front
Back
Side
Pain deep in shoulder joint
Diagnosed bursitis
Diagnosed Arthritis
Can't raise arm above shoulder level
Can't raise arm over head
Other
Arms & Hands Symptoms
Pain in upper arm
Pain in forearm
Pain in wrist
Pain in fingers
Sensation of pins & needles in arm
Sensation of pins & needles in fingers
Fingers go to sleep
Hands cold
Swollen joints in fingers
Sore joints in fingers
Diagnosed arthritis
Loss of grip strength
Other
Mid-Back Symptoms
Mid-back pain
Pain between shoulder blades
Pain up/down back
Pain across mid back
Pain with breathing
Other
Low Back Symptoms
Low back pain
Low back pain is worse when working
Low back pain is worse when lifting
Low back pain is worse when stooping
Low back pain is worse when standing
Low back pain is worse when sitting
Low back pain is worse when bending
Low back pain is worse when coughing
Pinched nerve in low back
Low back feels out of place
Pain up/down low back
Pain across low back
Diagnosed disc herniation
Other
Hip Symptoms
Pain in buttocks
Pain in buttocks when standing
Pain buttocks in buttocks when sitting
Pain on side of hip
Pain deep in hip joint
Pain on sit bone
Diagnosed bursitis
Diagnosed arthritis
Other
Legs and Feet Symptoms
Pain down RIGHT leg
Pain down LEFT leg
Pain down BOTH legs
Leg cramps
Pin & Needles in RIGHT leg
Pin & Needles in LEFT leg
Numbness in RIGHT leg
Numbness in LEFT leg
Numbness in RIGHT foot
Numbness in LEFT foot
Numbness in toes
Feet feel cold
Cramps in RIGHT foot
Cramps in LEFT foot
Swollen RIGHT ankle
Swollen LEFT Ankle
Swollen RIGHT foot
Swollen LEFT foot
Pain in RIGHT Foot
Pain in LEFT Foot
Pain in RIGHT knee
Pain in LEFT knee
Diagnosed Arthritis
Other
Client information are confidential and written authorization is required to release any information. We do not double book appointments Please reschedule session if more than 15 minutes late 24 hour cancellation notice is required You will be draped and at no time be exposed You will have a consultation with your therapist to discuss the session You my end the session at any time for any reason Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law Client Agreement: I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder. 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. I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction. I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status. By my electronic signature below, I agree to the massage policy and client agreement above.
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