Evett Cadogan's Clinic
Health Intake Form
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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)
Ear Blockage
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Ear Pressure
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Ear Ringing
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Ear Stuffiness
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Clenching
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Grinding
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Clicking
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Jaw Pain
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Difficulty Chewing
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Locking
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Difficulty Opening Jaw
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Morning Stiffness
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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
Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Rebound
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Sinus
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Tension
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Other Headaches
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Skin
Athlete's Foot
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Non-Surgical Scars
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Bruise Easily
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Plantar's Wart
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Eczema
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Psoriasis
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Herpes
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Rash
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Infectious Skin Conditions
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Severe Irritability
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Melanoma
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Skin Conditions
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Melanoma/Carcinoma
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Surgical Scars
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Acne
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Moles
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Sensitive Skin
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Musculoskeletal
Osteoporosis
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Temporomandibular Joint Dysfunction
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Bone Disease
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Fibromyalgia
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Paget Disease
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Tendonitis/Bursitis
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Bone or Joint Disease
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Fracture
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Plantar Fasciitis
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Torticollis
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Broken Bone / Fracture
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Gout
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Psoriatic Arthritis
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Whiplash
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Carpal Tunnel Syndrome
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Hereditary/Congenital Deformity
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Scoliosis
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Chronic Fatigue Syndrome
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Jaw Pain (TMJD)
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Sinus Problems
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Arthritis
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Chronic Myofascial Pain Syndrome
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Joint Injury
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Spasms / Cramps
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Artificial Joints / Special Equipment
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Degenerative Disk Disease
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Joint Stiffness / Swelling
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Osteoarthritis
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Strain/Sprain
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Baker's Cyst
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Dislocation
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Other Musculoskeletal
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Cardiovascular
Myocardial infarction
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Atherosclerosis
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Congenital Heart Defect
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Pacemaker
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Blood Clots
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Coronary Artery Disease
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Pericarditis
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Blood Pressure
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Fainting Spells
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Stroke
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Cardiac Arrhythmia
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Heart Attack
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Swelling
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Cardiovascular Conditions
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Heart Disease
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High Blood Pressure
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Valve Disorders
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Chest Pain
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Low Blood Pressure
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Varicose Veins
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Aneurysm
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Cold Feet
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Lymphedema
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Angina
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Cold Hands
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Other Cardiovascular
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Neurological
Shingles / Herpes
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Burning
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Loss of Sensation
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Sleeping Disorders
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Carpal Tunnel
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Multiple Sclerosis
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Stroke
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Cerebral Palsy
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Numbness
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Parkinsons
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Tingling
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Chronic Pain Disorder
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Peripheral Neuropathy
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Transient Ischemic Attacks (TIA)
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Dizziness
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Post Polio Syndrome
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Twitching of Face
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Bell's Palsy
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Epilepsy
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Sciatic Pain
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Vertebral and Spinal Cord Injury
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Brain Disorder
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Fatigue
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Seizure Disorder
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Brain Injury
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Herniated Disc
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Other Neurological
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Hearing
Motion Sickness
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Vertigo
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Blood
Anemia
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Bleeding Disorder
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Blood Thinner Medication
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Haemophilia
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Hepatitis
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High Cholesterol
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Family History
Arthritis
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Cancer
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Cardiovascular
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Diabetes
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Respiratory
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Reproductive
Pregnancy
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Other Reproductive
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Respiratory
Infectious Respiratory Conditions
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Respiratory Conditions
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Asthma
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Respiratory Tract Infection
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Bronchitis
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Shortness of Breath
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Chronic Cough
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Sinus Problem
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COPD
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Tuberculosis
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Cystic Fibrosis
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Emphysema
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Other Respiratory
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Kidney
Chronic Kidney Disease
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Congenital Kidney Disease
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Other Kidney
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Gastrointestinal
Abdominal Hernia
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Hiatal Hernia
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Miscellaneous
Loss of Balance
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Surgical Pins or Wire
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Weakened Immune Function
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Other Medical Conditions
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Other Diagnosed Diseases
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Massage Goals
Address Health Issues
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Balance
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Flexibility
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Improve Fitness
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Increase Well-Being
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Positive Reinforcement
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Stress Relief
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Other
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