Darla Ricka, Registered Massage Therapist
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Right Arm
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Right Calf
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Right Gluteal
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Left Hip
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Left Foot
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Right Foot
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Headaches
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Tension
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Fibromyalgia
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Tethered Cord
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Multiple Sclerosis
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Post Polio Syndrome
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Huntington Disease
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Brain Disorder
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Stabbing
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Dural Ectasia
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Sleeping Disorders
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Cerebral-vascular Accident
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Brain Injury
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Carpal Tunnel
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Bell's Palsy
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Athlete's Foot
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Athletes Foot
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Arthritis
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Scoliosis
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Spondylolisthesis
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Torticollis
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Joint Injury
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Gout
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Osteoporosis
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Amyotrophic Lateral Sclerosis (ALS)
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Temporomandibular Joint Dysfunction
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Joint Stiffness / Swelling
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Spasms / Cramps
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Baker's Cyst
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Osgood-Schlatter Disease
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Ehlers-Danlos Syndrome
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Muscular Dystrophy
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Cardiovascular
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Angina
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Raynaud Disease
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Phlebitis
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Chest Pain
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Atherosclerosis
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Rheumatic Heart Disease
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Heart Condition
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Cardiac Arrhythmia
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Myocardial infarction
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Peripheral Vascular Disease
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Valve Disorders
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Cardiovascular Accident
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Stroke
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Chronic Ischemic Heart Disease
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Varicose Veins
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Swelling
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Pacemaker
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Fainting Spells
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Postural Orthostatic Tachycardia Syndrome
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Blood Clots
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High Blood Pressure
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Cardiovascular Conditions
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Heart Disease
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Lymphedema
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Blood Pressure
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Congenital Heart Defect
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Cold Hands
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Low Blood Pressure
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Acute Coronary Syndrome
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Coronary Artery Disease
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Hyperlipidemia
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Cold Feet
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Congestive Heart Failure
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Aneurysm
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Other Cardiovascular
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Respiratory
Chronic Cough
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Shortness of Breath
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Respiratory Tract Infection
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Asthma
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COPD
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Emphysema
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Cystic Fibrosis
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Bronchitis
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Sinus Problem
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Respiratory Conditions
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Infectious Respiratory Conditions
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Tuberculosis
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Other Respiratory
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Blood
Hepatitis
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High Cholesterol
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Bleeding Disorder
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Thrombosis/Embolism
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Anemia
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Hearing
Tinnitus
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Vertigo
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Ear Problems
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Conductive Hearing Loss
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Hearing Loss
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Meniere Disease
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Motion Sickness
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Other Hearing
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Reproductive
Endometriosis
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Pregnancy
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Premenstrual Syndrome
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Menopause
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Ovarian Cysts/Tumors
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Menstrual Cycle Disorder
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Gynaecological Conditions
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Breast Disorder
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Other Reproductive
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Endocrine
Adrenal Fatigue
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Hyperthyroidism
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Diabetes
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Prostate Condition
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Hypothyroidism
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Temiskaming Diabetes Program
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Pituitary and Growth Disorder
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Blood Sugar Managed?
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Wound Healing Status?
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Acute Pancreatitis
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Other Endocrine
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Family History
Arthritis
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Cancer
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Cardiovascular
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Respiratory
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Diabetes
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Gastrointestinal
Stomach Disorders
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Esophageal Disorder
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Intestinal Gas/Bloating
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Fecal Impaction
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Adaptive Aids
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Intestinal Polyps
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Irritable Bowel Syndrome
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Crohn's Disease
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Celiac Disease
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Poor Appetite
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Constipation
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Stomach Disorder
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Abdominal Hernia
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Diarrhea
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Digestive Conditions
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Gastroparesis
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Ulcerative Colitis
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Acid Reflux
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Diverticulitis
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Hiatal Hernia
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Eating Disorder
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Other Gastrointestinal
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Immune
Allergies
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Hodgkin Lymphoma
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CVID
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Infectious Mononucleosis
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Cancer
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HIV/Aids
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Leukemia
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Rheumatoid Arthritis
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Non-Hodgkin Lymphoma
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Anaphylaxis
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Sjogren's Syndrome
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Lupus
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Other Immune
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Kidney
Kidney Stones
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Urinary Incontinence
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Urinary Tract Infection
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Chronic Kidney Disease
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Miscellaneous
Vision Problems
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Surgical Pins or Wire
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Vision Loss
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ADHD
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Insomnia
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Liver Disease
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Mental Health Issues
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
Due Date
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Trimester
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Weeks Pregnant
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Number of previous pregnancies/births?
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Anemia
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Leaking Amniotic Fluid
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Bladder Infection
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Blood Clot (Phlebitis)
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Miscarriage
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Nausea
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Problems with Placenta
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Preterm Labour
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Pre-eclampsia (toxemia)
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Sciatica
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Separation of Rectus Muscle (diastasis recti)
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Separation of Symphysis Pubis
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Twins or More
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Visual Disturbances
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Previous C-Section
Characters:
0
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Heart Attack
Characters:
0
/255
Stroke
Characters:
0
/255
Carpal Tunnel Syndrome
Characters:
0
/255
Allergy to Nut Oils
Characters:
0
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Hypoglycemia
Characters:
0
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High Risk Pregnancy
Characters:
0
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Birth Location
Characters:
0
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Doula
Characters:
0
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Placental Location
Characters:
0
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Baby's Sex
Characters:
0
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Sacral Injury
Characters:
0
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Tailbone Injury
Characters:
0
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Massage Goals
Alternative Therapy
Characters:
0
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Stress Relief
Characters:
0
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Balance
Characters:
0
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Flexibility
Characters:
0
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Improve Fitness
Characters:
0
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Increase Well-Being
Characters:
0
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Injury Rehabilitation
Characters:
0
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Positive Reinforcement
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0
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Address Health Issues
Characters:
0
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Strength Training
Characters:
0
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Massage Frequency
Characters:
0
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Other
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0
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Which best describes what you are experiencing
Pain
Characters:
0
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Mild
Characters:
0
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Getting Worse
Characters:
0
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Ache
Characters:
0
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Moderate
Characters:
0
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Staying the Same
Characters:
0
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Tension
Characters:
0
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Disabling
Characters:
0
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Getting Better
Characters:
0
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Discomfort
Characters:
0
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Constant
Characters:
0
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Imbalance
Characters:
0
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Intermittent
Characters:
0
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Increases with Activity
Characters:
0
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Decreases with Activity
Characters:
0
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No Change
Characters:
0
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Other
Characters:
0
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Allergy
MCAD
Characters:
0
/255
Mastocytosis
Characters:
0
/255
Food
Characters:
0
/255
Environmental
Characters:
0
/255
Medical
Characters:
0
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Latex
Characters:
0
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Review & Agree
Darla Ricka, RMT - Consent to Massage Therapy
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