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Emergency Contact
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Relationship
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Medical Info
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General Health
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Additional Info
Conditions
Feet
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Itchy or Peeling Skin
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Onychocryptosis (Ingrown Nail)
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Plantar Fasciitis
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Plantar Wart
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Previous Amputations
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Bunions
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Health Questions
Depression
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Epilepsy
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Hearing Impairment
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Congenital Heart Defect
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Emotion / Memory
Mood Disorder
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Schizophrenia
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Substance Use Disorder
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Female Health
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Energy
Does your energy fluctuate?
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How long do you sleep on average?
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Do you struggle with insomnia?
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Treatment Goals
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Rehabilitation
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Stress Relief
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Improve Symptoms
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Well Being
Exercise
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Hobbies
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Mobility/Walking Aids
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Energy Level
Agitated
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Dull
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Fatigue
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Genetics
Down Syndrome
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Other
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Oncology
Cancer Type
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Date of Diagnosis
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Treatment: Chemotherapy
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Side Effects of Chemo
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Treatment: Radiation
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Side Effects of Radiation
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Pressure Sensitivity
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Edema
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Lymphedema
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Heart Condition
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Lung Condition
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Fragile Skin
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Infectious Condition
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Enlarged Lymph Nodes
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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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Brain Disorders
PTSD
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ADD
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ADHD
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Asperger Syndrome
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Obsessive Compulsive Disorder
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Headaches
Chronic Daily Headache
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Cluster
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Migraines
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Cardiovascular
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Blood Clots
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Varicose Veins
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Cardiovascular Conditions
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Heart Condition
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High Blood Pressure
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Low Blood Pressure
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Pacemaker
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Reproductive
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Premenstrual Syndrome
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Musculoskeletal
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Carpal Tunnel Syndrome
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Strain/Sprain
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Fibromyalgia
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Whiplash
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Joint Stiffness / Swelling
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Arthritis
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Osteoarthritis
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Artificial Joints / Special Equipment
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Osteoporosis
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Bone or Joint Disease
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Plantar Fasciitis
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Scoliosis
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Respiratory
Respiratory Conditions
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Asthma
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Bronchitis
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COPD
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Emphysema
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Other Respiratory
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Gastrointestinal
Digestive Conditions
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Irritable Bowel Syndrome
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Stomach Disorders
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Ulcerative Colitis
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Acid Reflux
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Skin
Skin Conditions
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Athlete's Foot
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Bruise Easily
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Eczema
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Infectious Skin Conditions
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Plantar's Wart
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Psoriasis
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Allergic to Iodine
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Mature Skin
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Immune
Infectious Mononucleosis
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Leukemia
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Lupus
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Rheumatoid Arthritis
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Allergies
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HIV/Aids
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Neurological
Fibromyalgia
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Multiple Sclerosis
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Parkinsons
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Sciatic Pain
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Seizure Disorder
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Bell's Palsy
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Stroke
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Brain Injury
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Cerebral Palsy
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Epilepsy
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Other Neurological
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Blood
Bleeding Disorder
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Blood Thinner Medication
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Haemophilia
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Hepatitis
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HIV/AIDS
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Thrombosis/Embolism
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Endocrine
Blood Sugar Managed?
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Diabetes
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Hyperthyroidism
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Hypothyroidism
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Pituitary and Growth Disorder
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Hearing
Hearing Loss
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Vertigo
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Miscellaneous
Vision Problems
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Weakened Immune Function
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ADHD
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Autism
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Hearing Impaired
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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)
Trimester
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Weeks Pregnant
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Diabetes
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Edema/Swelling
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Preterm Labour
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Sciatica
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Twins or More
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High Risk Pregnancy
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Massage Goals
Injury Rehabilitation
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Positive Reinforcement
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Strength Training
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Stress Relief
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Alternative Therapy
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Balance
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Flexibility
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Increase Well-Being
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Date of Last Massage
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Massage Frequency
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Other
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Accident Info
Date of Injury
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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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Allergy
Environmental
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Food
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Latex
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Emotion / Mood
Fear
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Grief
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Mental Abuse History
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Overall mood and energy level
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Anger
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Physical Abuse History
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Anxiety
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PTSD
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Confusion
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Rate the stress in your life (1-10)
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Depression
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