Sarayu Wellness
Intake Form
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Samoa
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Senegal
Serbia
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Slovenia
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Somalia
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South Georgia And The South Sandwich Islands
Spain
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Sudan
Suriname
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Swaziland
Sweden
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Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
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Tokelau
Tonga
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Turkey
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Uganda
Ukraine
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Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
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Province / State
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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
TMJ (Jaw)
Jaw Pain
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Ear Ringing
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Clenching
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Locking
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Ear Pressure
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Morning Stiffness
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Ear Stuffiness
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Grinding
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Clicking
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Difficulty Chewing
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Female Health
Hysterectomy
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Oncology
Cancer Type
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Status
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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 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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Sacrum
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Tailbone (coccyx)
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Headaches
Headaches
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Cluster
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Rebound
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Sinus
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Chronic Daily Headache
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Tension
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Migraines
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Other Headaches
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Brain Disorders
Obsessive Compulsive Personality Disorder
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ADD
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PTSD
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Sleep Disorder
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Social Anxiety Disorder
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Generalized Anxiety Disorder
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Depression
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Bipolar Disorder
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Cardiovascular
Heart Disease
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Coronary Artery Disease
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High Blood Pressure
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Cold Feet
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Low Blood Pressure
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Congestive Heart Failure
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Blood Clots
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Cardiovascular Accident
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Lymphedema
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Cold Hands
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Blood Pressure
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Cardiovascular Conditions
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Stroke
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Raynaud Disease
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Cardiac Arrhythmia
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Other Cardiovascular
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Skin
Rash
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Athletes Foot
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Bruise Easily
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Rosacea
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Chemical Burn
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Infectious Skin Conditions
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Moles
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UV Burn
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Hypersensitive Reactions
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Athlete's Foot
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Herpes
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Cosmetic Surgery
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Severe Irritability
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Melanoma/Carcinoma
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Non-Surgical Scars
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Pigmentary Disorder
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Eczema
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Skin Conditions
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Surgical Scars
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Plantar's Wart
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Skin Irritations
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Acne
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Psoriasis
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Melanoma
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Hypersensitive Reaction
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Allergic Dermatosis
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Allergic to Iodine
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Combination Skin
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Dry Skin
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Oily Skin
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Mature Skin
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Sensitive Skin
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Sun Damage
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Using ALPHA Hydroxy Acids
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Using RETIN A
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Other Skin
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Neurological
Dizziness
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Parkinsons
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Cerebrospinal Fluid Leak
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Carpal Tunnel
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Brain Disorder
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Herniated Disc
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Dural Ectasia
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Chronic Pain Disorder
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Bell's Palsy
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Multiple Sclerosis
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Stroke
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Brain Injury
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Cerebral Vascular Accident (Stroke)
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Peripheral Neuropathy
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Fibromyalgia
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Post Polio Syndrome
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Seizure Disorder
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Numbness
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Shingles / Herpes
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Transient Ischemic Attacks (TIA)
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Chiari Malformation
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Cerebral-vascular Accident
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Burning
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Twitching of Face
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Loss of Sensation
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Sciatic Pain
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Syringomyelia
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Tingling
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Fatigue
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Vertebral and Spinal Cord Injury
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Shingles
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Epilepsy
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Cerebral Palsy
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Tethered Cord
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Stabbing
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Sleeping Disorders
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Huntington Disease
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Other Neurological
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Reproductive
Endometriosis
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Menopause
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Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Other Reproductive
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Musculoskeletal
Dislocation
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Arthritis
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Bone or Joint Disease
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Scleroderma
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Sinus Problems
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Dupuytren's Contracture
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Jaw Pain (TMJD)
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Fracture
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Osteoporosis
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Carpal Tunnel Syndrome
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Joint Stiffness / Swelling
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Scoliosis
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Fibromyalgia
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Chronic Myofascial Pain Syndrome
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Hereditary/Congenital Deformity
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Spasms / Cramps
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Temporomandibular Joint Dysfunction
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Strain/Sprain
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Chronic Fatigue Syndrome
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Joint Injury
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Artificial Joints / Special Equipment
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Osteoarthritis
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Amyotrophic Lateral Sclerosis (ALS)
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Spondylolisthesis
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Torticollis
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Osgood-Schlatter Disease
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Muscular Dystrophy
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Ehlers-Danlos Syndrome
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Baker's Cyst
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Ankylosing Spondylitis
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Osteomalacia
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Degenerative Disk Disease
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Myasthenia Gravis
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Recti Diastasis
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Gout
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Bone Disease
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Paget Disease
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Whiplash
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Compartment Syndrome
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Tendonitis/Bursitis
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Broken Bone / Fracture
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Psoriatic Arthritis
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Plantar Fasciitis
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Other Musculoskeletal
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Gastrointestinal
Constipation
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Ulcerative Colitis
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Stomach Disorder
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Diarrhea
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Irritable Bowel Syndrome
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Celiac Disease
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Poor Appetite
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Digestive Conditions
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Other Gastrointestinal
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Kidney
Chronic Kidney Disease
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Urinary Tract Infection
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Kidney Stones
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Urinary Incontinence
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Bladder Disorder
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Endocrine
Acute Pancreatitis
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Hypothyroidism
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Blood Sugar Managed?
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Hyperthyroidism
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Diabetes
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Hearing
Tinnitus
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Conductive Hearing Loss
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Hearing Loss
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Vertigo
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Motion Sickness
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Family History
Arthritis
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Diabetes
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Cancer
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Respiratory
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Cardiovascular
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Blood
Bleeding Disorder
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Anemia
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Thrombosis/Embolism
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Blood Thinner Medication
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High Cholesterol
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Other Blood
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Immune
Cancer
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Allergies
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Lupus
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Rheumatoid Arthritis
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Other Immune
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Respiratory
Shortness of Breath
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Asthma
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Cystic Fibrosis
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Other Respiratory
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Miscellaneous
Music Preference
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Surgical Pins or Wire
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Vision Problems
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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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Miscarriage
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Massage Goals
Strength Training
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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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Balance
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Improve Fitness
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Increase Well-Being
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Positive Reinforcement
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Massage Frequency
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Other
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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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Emotion / Mood
Other Emotions
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Overall mood and energy level
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Anger
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Anxiety
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Grief
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Depression
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Sadness
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Despair
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Fear
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PTSD
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Stress Response and Coping Strategies
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Negative Self-Talk
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Rate the stress in your life (1-10)
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