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Claims / Benefit
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Area of Complaint
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Mid Back
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Left Hand
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Left Leg
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Left Thigh
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Bruise Easily
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Cosmetic Surgery
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Endocrine
Diabetes
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Hypothyroidism
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Reproductive
Ovarian Cysts/Tumors
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Pregnancy
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Gynaecological Conditions
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Ectopic Pregnancy
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Musculoskeletal
Joint Stiffness / Swelling
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Osteoporosis
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Spasms / Cramps
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Recti Diastasis
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Whiplash
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Psoriatic Arthritis
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Jaw Pain (TMJD)
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Scoliosis
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Carpal Tunnel Syndrome
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Strain/Sprain
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Osteoarthritis
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Arthritis
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Other Musculoskeletal
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Neurological
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Shingles
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Fatigue
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Sciatic Pain
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Dizziness
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Carpal Tunnel
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Bell's Palsy
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Herniated Disc
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Numbness
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Immune
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Cardiovascular Conditions
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Low Blood Pressure
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Varicose Veins
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Swelling
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Raynaud Disease
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Hearing
Ear Problems
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Blood
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Gastrointestinal
Constipation
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Eating Disorder
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Acid Reflux
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Hiatal Hernia
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Digestive Conditions
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Other Gastrointestinal
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Miscellaneous
Mental Health Issues
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Surgical Pins or Wire
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Hearing Impaired
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Insomnia
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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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Weeks Pregnant
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Diabetes
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Edema/Swelling
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Leg Cramps
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Nausea
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Sciatica
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Separation of Symphysis Pubis
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Twins or More
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Carpal Tunnel Syndrome
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High Risk Pregnancy
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Birth Location
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Doula
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Baby's Sex
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Massage Goals
Address Health Issues
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Alternative Therapy
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Increase Well-Being
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Injury Rehabilitation
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Stress Relief
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Other
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Accident Info
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Which best describes what you are experiencing
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Getting Better
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Constant
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Intermittent
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Increases with Activity
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Decreases with Activity
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