Therapeutic Healing and Wellness Centre
Intake Form
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Senegal
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Slovenia
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Tanzania, United Republic Of
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Province / State
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Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
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Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Well Being
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Improve Symptoms
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Pain Relief
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Stress Relief
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Other
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Energy
How long do you sleep on average?
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Do you struggle with insomnia?
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TMJ (Jaw)
Locking
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Difficulty Opening Jaw
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Difficulty Chewing
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Clenching
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Morning Stiffness
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Ear Ringing
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Ear Stuffiness
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Jaw Pain
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Ear Pressure
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Grinding
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Clicking
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Ear Blockage
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Feet
Pes Cavus (High Arch)
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Bunions
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Overlapping Toes
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Corns/Callouses
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Itchy or Peeling Skin
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Dry/Cracked Skin
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Heel Fissures
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Pes Planus (Flat Feet)
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Yoga
Have Practiced Yoga
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Area of Complaint
Neck
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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 Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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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 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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Sacrum
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Headaches
Sinus
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Chronic Daily Headache
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Migraines
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Tension
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Headaches
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Cluster
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Rebound
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Other Headaches
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Endocrine
Prostate Condition
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Hypothyroidism
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Pituitary and Growth Disorder
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Blood Sugar Managed?
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Diabetes
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Adrenal Fatigue
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Acute Pancreatitis
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Hyperthyroidism
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Other Endocrine
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Kidney
Congenital Kidney Disease
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Electrolyte Imbalance
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Kidney Stones
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Renal Cysts
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Urinary Incontinence
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Urinary Tract Infection
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Bladder Disorder
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Chronic Kidney Disease
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Other Kidney
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Cardiovascular
Heart Attack
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Cardiovascular Conditions
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Stroke
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Cardiac Arrhythmia
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Lymphedema
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Rheumatic Heart Disease
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Phlebitis
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Fainting Spells
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Chronic Ischemic Heart Disease
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Valve Disorders
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Cold Hands
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Chronic Venous Insufficiency
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Cold Feet
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Cardiovascular Accident
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Congenital Heart Defect
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Blood Pressure
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Pacemaker
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Acute Coronary Syndrome
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Coronary Artery Disease
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Swelling
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Heart Disease
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Aneurysm
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Hyperlipidemia
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Postural Orthostatic Tachycardia Syndrome
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High Blood Pressure
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Chest Pain
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Angina
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Pericarditis
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Myocardial infarction
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Low Blood Pressure
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Heart Condition
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Atherosclerosis
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Blood Clots
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Raynaud Disease
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Varicose Veins
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Congestive Heart Failure
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Other Cardiovascular
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Reproductive
Pelvic Inflammatory Disease
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Premenstrual Syndrome
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Uterine Disorder
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Pregnancy
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Breast Disorder
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Endometriosis
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Gynaecological Conditions
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Menopause
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Menstrual Cycle Disorder
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Enlarged Prostate
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Ovarian Cysts/Tumors
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Other Reproductive
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Immune
Hodgkin Lymphoma
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Anaphylaxis
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HIV/Aids
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Rheumatoid Arthritis
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Infectious Mononucleosis
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Leukemia
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Lupus
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Non-Hodgkin Lymphoma
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Allergies
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Cancer
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Sjogren's Syndrome
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Other Immune
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Musculoskeletal
Torticollis
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Compartment Syndrome
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Scleroderma
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Degenerative Disk Disease
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Carpal Tunnel Syndrome
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Baker's Cyst
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Dislocation
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Gout
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Broken Bone / Fracture
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Scoliosis
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Recti Diastasis
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Fracture
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Osteoporosis
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Plantar Fasciitis
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Bone or Joint Disease
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Strain/Sprain
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Sinus Problems
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Hereditary/Congenital Deformity
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Muscular Dystrophy
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Joint Injury
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Artificial Joints / Special Equipment
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Chronic Myofascial Pain Syndrome
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Spasms / Cramps
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Fibromyalgia
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Whiplash
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Osgood-Schlatter Disease
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Jaw Pain (TMJD)
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Chronic Fatigue Syndrome
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Ankylosing Spondylitis
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Osteomalacia
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Spondylolisthesis
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Temporomandibular Joint Dysfunction
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Tendonitis/Bursitis
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Bone Disease
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Arthritis
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Psoriatic Arthritis
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Osteoarthritis
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Other Musculoskeletal
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Skin
Hypersensitive Reactions
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Melanoma/Carcinoma
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Plantar's Wart
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Herpes
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Psoriasis
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Rash
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Eczema
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Rosacea
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Bruise Easily
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Skin Conditions
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Acne
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Athlete's Foot
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Infectious Skin Conditions
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Skin Irritations
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Allergic Dermatosis
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Surgical Scars
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Other Skin
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Gastrointestinal
Digestive Conditions
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Esophageal Disorder
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Intestinal Polyps
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Abdominal Hernia
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Celiac Disease
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Irritable Bowel Syndrome
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Acid Reflux
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Constipation
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Poor Appetite
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Hiatal Hernia
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Diarrhea
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Stomach Disorder
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Stomach Disorders
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Diverticulitis
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Ulcerative Colitis
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Intestinal Gas/Bloating
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Eating Disorder
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Crohn's Disease
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Other Gastrointestinal
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Blood
Hepatitis
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Anemia
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Haemophilia
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Thrombosis/Embolism
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HIV
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Bleeding Disorder
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Blood Thinner Medication
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HIV/AIDS
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Stroke
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Hypercoagulability
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Fainting Spells
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Polycythemia
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High Cholesterol
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Other Blood
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Family History
Respiratory
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Cancer
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Diabetes
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Arthritis
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Cardiovascular
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Neurological
Cerebral-vascular Accident
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Fatigue
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Cerebral Vascular Accident (Stroke)
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Sleeping Disorders
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Seizure Disorder
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Stroke
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Loss of Sensation
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Cerebral Palsy
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Transient Ischemic Attacks (TIA)
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Shingles
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Parkinsons
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Numbness
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Burning
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Dizziness
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Vertebral and Spinal Cord Injury
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Herniated Disc
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Sciatic Pain
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Post Polio Syndrome
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Stabbing
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Epilepsy
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Fibromyalgia
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Huntington Disease
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Multiple Sclerosis
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Shingles / Herpes
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Chronic Pain Disorder
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Twitching of Face
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Brain Injury
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Other Neurological
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Respiratory
Chronic Cough
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Respiratory Conditions
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Shortness of Breath
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Asthma
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Sinus Problem
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Respiratory Tract Infection
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Emphysema
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COPD
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Bronchitis
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Cystic Fibrosis
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Tuberculosis
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Infectious Respiratory Conditions
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Other Respiratory
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Hearing
Conductive Hearing Loss
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Meniere Disease
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Ear Problems
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Motion Sickness
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Hearing Loss
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Tinnitus
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Vertigo
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Other Hearing
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Miscellaneous
Vision Problems
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Weakened Immune Function
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Contact Lens
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Vision Loss
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Surgical Pins or Wire
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Liver Disease
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Insomnia
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Visually Impaired
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Loss of Balance
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Upper Respiratory Infection
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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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Nausea
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Sciatica
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Allergy to Nut Oils
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Massage Goals
Injury Rehabilitation
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Stress Relief
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Address Health Issues
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Alternative Therapy
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Flexibility
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Increase Well-Being
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Other
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Which best describes what you are experiencing
Pain
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Mild
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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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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Allergy
Latex
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Food
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Environmental
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Medical
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Emotion / Mood
Overall mood and energy level
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Rate the stress in your life (1-10)
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Anxiety
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Depression
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Grief
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Other Emotions
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PTSD
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