Health History
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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
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Conditions
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Improve Symptoms
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Pain Relief
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Rehabilitation
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Stress Relief
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Health Advice for Healing
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Other
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TMJ (Jaw)
Jaw Pain
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Health Questions
Heart Attack
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Stroke
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Area of Complaint
Neck
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Upper Back
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Mid Back
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Low Back
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Chest
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Left Arm
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Right Arm
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Left Leg
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Right Leg
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Left Hip
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Right Hip
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Left Ankle
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Right Ankle
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Sacrum
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Tailbone (coccyx)
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Headaches
Migraines
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Sinus
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Tension
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Other Headaches
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Musculoskeletal
Broken Bone / Fracture
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Strain/Sprain
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Fibromyalgia
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Fracture
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Jaw Pain (TMJD)
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Osteoarthritis
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Plantar Fasciitis
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Scoliosis
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Cardiovascular
Congestive Heart Failure
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Heart Attack
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Heart Disease
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High Blood Pressure
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Low Blood Pressure
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Stroke
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Varicose Veins
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Respiratory
Bronchitis
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Chronic Cough
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Emphysema
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Asthma
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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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Neurological
Carpal Tunnel
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Numbness
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Sciatic Pain
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Hearing
Hearing Loss
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Tinnitus
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Blood
Hepatitis
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HIV/AIDS
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Stroke
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Reproductive
Menopause
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Pregnancy
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Immune
Allergies
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Other Immune
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Endocrine
Diabetes
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Prenatal (check boxes to enter details below)
Due Date
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Trimester
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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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Pre-eclampsia (toxemia)
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Sciatica
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High Risk Pregnancy
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Massage Goals
Improve Fitness
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Increase Well-Being
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Injury Rehabilitation
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Stress Relief
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Address Health Issues
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Flexibility
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Light Pressure Preferred
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Medium Pressure Preferred
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Other
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Accident Info
Date of Injury
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Which State?
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Allergy
Environmental
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Food
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Latex
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Miscellaneous
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