Myopathic Muscular Therapy Clinic
Patient Health History Form
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
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
Insurance Info
Insurer's Name
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Adjuster's Name
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Policy Number
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Office Address
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Unit #
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City
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Country
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Prov / State
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Postal Code / Zip
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Phone
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Fax
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Email Address
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Claims / Benefit
Conditions
Health Questions
Past Heart Surgery
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Depression
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Schizophrenia
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Epilepsy
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Stroke
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Hearing Impairment
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Vertigo
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Heart Attack
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Heart Condition
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Asthma
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Meniere Disease
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Concussion
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Mood Disorder
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Pacemaker
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Congenital Heart Defect
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KID/UB (Water)
Thyroid Problems
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Craving/Avoiding Salty Foods
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Hearing Problems
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Urinary Problems
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Dark Under Eyes
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Hot Flash/Night Sweating
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Weak Leg/Knees
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Decrease Bone Density
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Lack of Bladder Control
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Weakness/Pain in Lower Back
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Emotional Instability
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Loss of Hair
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Excess Worry
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Low Sex Drive
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Bladder Problems
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Excessive Sexual Drive
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Poor Memory
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Brain Foggy
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Fear
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Rapid Weight Change
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Tendency to Gain Weight
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Cavities/Tooth Loss
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Feel Cold Easily
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Feet
Itchy or Peeling Skin
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Pes Planus (Flat Feet)
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Bunions
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Mallet Toe
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Plantar Fasciitis
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Claw Toe
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Onychauxis
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Plantar Wart
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Corns/Callouses
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Onychocryptosis (Ingrown Nail)
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Previous Amputations
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Dry/Cracked Skin
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Onychomycosis (Nail Fungus)
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Thickened Nails
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Hallux Valgus
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Onychoptosis (Nail Loss)
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Yellow Nails
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Hammer Toe
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Overlapping Toes
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Heel Fissures
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Involuted Nails (Curved/Pinched)
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Pes Cavus (High Arch)
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SP/ST (Earth)
Decreased/Increased Appetite
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Heaviness Anywhere in Body
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Diarrhea
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Hemorrhoids
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Difficulty Digesting Fats/Oils
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Hypoglycemia
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Easily Bruising & Bleeding
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Indigestion/Heartburn
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Abdominal Pain
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Edema (Swelling)
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Insulin Sensitivity
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Bad Breath
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Fatigue/Worse After Eating
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Muscles Feel Tired Often
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Constipation
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Gas/Belching
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Nausea/Vomiting
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Crave Sweets
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Hard to Get Up In AM
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Over-Thinking
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LU/LI (Metal)
Dry Cough
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Skin Rashes/Hives
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Dry Mouth/Throat/Nose
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Sneezing
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Grief/Sadness
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Snoring
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Low Resistance to Colds/Flu
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Nasal Discharge
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Asthma/Allergies
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Post-Nasal Drip
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Bronchitis
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Shortness of Breath
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Cough with Sputum
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Sinus Trouble
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HT/SI (Fire)
Restlessness/Agitation
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Chest Pain
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Heart Palpitations
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Skin Rash
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Cysts/Tumor
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Hot Palms/Soles
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Sore Throat
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Dry Scalp
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Insomnia/Sleep Problems
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Itchy/Burning Skin
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Thirst
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Ear Infection
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Lack of Joy in Life
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Vivid Dreams
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Easily Startled
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Lymph Swelling
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Excess Joy
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Night Sweats
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Aversion to Heat
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Facial Redness
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Nose Bleed
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Bitter Taste in Mouth
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Gum Problems
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LIV/GB (Wood)
Emotional Eater
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Intermittent Mild Fever
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Shoulder/Neck Tension
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Feeling of Lump in Throat
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Irritability/Anger
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Soft/Brittle Nails
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Fullness Below Ribs
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Joints/Neck/Shoulder Pain
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Teeth Clenching at Night
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Tension
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Gall Stones
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Muscle Cramping/Twitching
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Visual Problems
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Blurred Vision
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Headaches/Migraines
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Poor Circulation
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Depression/Stress
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Herpes Simplex
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Red/Dry/Itchy Eyes
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Dizziness
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Indecisive
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Ringing in Ears
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Eczema
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Insomnia 11pm-3am
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Shingles
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Genetics
Ehlers-Danlos Syndromes
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Loeys-Dietz Syndrome
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Marfan Syndrome
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Mitochondrial Disease
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Down Syndrome
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Other
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Energy
How long do you sleep on average?
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Is your energy constant?
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What is your energy level upon awakening?
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When is your energy highest?
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When is your energy lowest?
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Do you struggle with insomnia?
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Does your energy fluctuate?
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Energy Level
Dull
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Even
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Fatigue
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Flat
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High
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Low
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Agitated
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Vibrant
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Chaotic
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Clear
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Treatment Goals
Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Other
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Infectious
Epstein Barr
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Lyme Disease
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Pneumonia
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Strep
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
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Willing to wash hands before leaving clinic
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Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you been tested for COVID?
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Have you had the antibody test?
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Fever Over 100.4 degrees
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New Onset of Cough
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Sore Throat
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Shortness of Breath
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Fatigue
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Chills
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Nasal or sinus congestion
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Sudden onset body aches
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New rash or other skin changes
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Regular cardio exercise
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Contact with someone with COVID
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Contact with someone who was in contact with COVID
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Recent domestic air travel
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Recent international air travel
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Recent travel to area with high infection rates
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Been in group where social distancing not observed
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Spend time around anyone that is high risk
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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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Brain Disorders
Agoraphobia
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Claustrophobia
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Sleep Disorder
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Anorexia Nervosa
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Depression
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Social Anxiety Disorder
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Antisocial Personality Disorder
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Generalized Anxiety Disorder
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Asperger Syndrome
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Obsessive Compulsive Disorder
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Autism
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Obsessive Compulsive Personality Disorder
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Bipolar Disorder
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Panic Disorder
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Acute Stress Disorder
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Borderline Personality Disorder
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PTSD
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ADD
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ADHD
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Bulimia Nervosa
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Schizophrenia
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Headaches
Migraines
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Rebound
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Sinus
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Tension
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Chronic Daily Headache
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Cluster
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Headaches
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Other Headaches
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Musculoskeletal
Muscular Dystrophy
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Psoriatic Arthritis
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Broken Bone / Fracture
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Temporomandibular Joint Dysfunction
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Ehlers-Danlos Syndrome
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Amyotrophic Lateral Sclerosis (ALS)
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Myasthenia Gravis
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Recti Diastasis
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Fibromyalgia
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Ankylosing Spondylitis
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Osgood-Schlatter Disease
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Scleroderma
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Chronic Fatigue Syndrome
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Torticollis
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Fracture
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Arthritis
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Artificial Joints / Special Equipment
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Osteoarthritis
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Scoliosis
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Chronic Myofascial Pain Syndrome
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Whiplash
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Gout
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Baker's Cyst
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Osteomalacia
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Sinus Problems
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Compartment Syndrome
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Hereditary/Congenital Deformity
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Jaw Pain (TMJD)
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Bone Disease
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Osteoporosis
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Spasms / Cramps
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Degenerative Disk Disease
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Joint Injury
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Bone or Joint Disease
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Paget Disease
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Spondylolisthesis
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Dislocation
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Joint Stiffness / Swelling
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Plantar Fasciitis
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Strain/Sprain
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Dupuytren's Contracture
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Adhesive Capsulitis
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Other Musculoskeletal
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Cardiovascular
Low Blood Pressure
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Pacemaker
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Raynaud Disease
Characters:
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Stroke
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Cardiovascular Conditions
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Heart Disease
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High Blood Pressure
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Other Cardiovascular
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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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Miscellaneous
Surgical Pins or Wire
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Autism
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Upper Respiratory Infection
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Contact Lens
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Vision Loss
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Hearing Impaired
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Vision Problems
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Insomnia
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Visually Impaired
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0
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Liver Disease
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Loss of Balance
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Weakened Immune Function
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Mental Health Issues
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Music Preference
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0
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ADHD
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0
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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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0
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Alternative Therapy
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0
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Increase Well-Being
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0
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Injury Rehabilitation
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Stress Relief
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Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Medium Pressure Preferred
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Other
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Deep Pressure Preferred
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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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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Allergy
Environmental
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Food
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Latex
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Mastocytosis
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MCAD
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Medical
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Miscellaneous
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Emotion / Mood
Confusion
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Overall mood and energy level
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Depression
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Physical Abuse History
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Despair
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PTSD
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Fear
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Rate the stress in your life (1-10)
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Grief
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Sadness
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Mental Abuse History
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Stress Response and Coping Strategies
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Negative Self-Talk
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Anger
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Anxiety
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Other Emotions
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