Massage by Mandy Starks, LLC
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General Health
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Medications
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Additional Info
Conditions
Feet
Dry/Cracked Skin
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Onychocryptosis (Ingrown Nail)
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Previous Amputations
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Hallux Valgus
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Onychomycosis (Nail Fungus)
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Thickened Nails
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Hammer Toe
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Onychoptosis (Nail Loss)
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Yellow Nails
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Heel Fissures
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Involuted Nails (Curved/Pinched)
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Itchy or Peeling Skin
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Pes Planus (Flat Feet)
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Claw Toe
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Mallet Toe
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Plantar Fasciitis
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Corns/Callouses
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Onychauxis
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Plantar Wart
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Health Questions
Epilepsy
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Schizophrenia
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Hearing Impairment
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Heart Condition
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Asthma
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Congenital Heart Defect
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Pacemaker
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Depression
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Past Heart Surgery
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Treatment Goals
Improve Symptoms
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Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Improve Lifestyle
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Other
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TMJ (Jaw)
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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Morning Stiffness
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Difficulty Opening Jaw
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Ear Blockage
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Ear Pressure
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Ear Ringing
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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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Fever Over 38 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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Oncology
Cancer Type
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Female Health
Number of Pregnancies
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Breast Cancer
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Ovarian Cancer
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Currently Pregnant
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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
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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Migraines
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Other Headaches
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Skin
Pigmentary Disorder
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Surgical Scars
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Alopecia
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Herpes
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Plantar's Wart
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Urticaria
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Athlete's Foot
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Hypersensitive Reaction
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Psoriasis
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Using Accutane
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Athletes Foot
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Hypersensitive Reactions
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Rash
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UV Burn
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Bruise Easily
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Infectious Skin Conditions
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Rosacea
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Chemical Burn
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Melanoma
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Severe Irritability
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Acne
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Cosmetic Surgery
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Melanoma/Carcinoma
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Skin Conditions
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Allergic Dermatosis
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Dermatographia
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Moles
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Non-Surgical Scars
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Skin Irritations
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Eczema
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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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Other Skin
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Respiratory
Respiratory Tract Infection
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Asthma
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Shortness of Breath
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Bronchitis
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Sinus Problem
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Chronic Cough
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Tuberculosis
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COPD
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Cystic Fibrosis
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Emphysema
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Infectious Respiratory Conditions
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Respiratory Conditions
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Other Respiratory
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Musculoskeletal
Scoliosis
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Chronic Myofascial Pain Syndrome
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Whiplash
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Gout
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Osteoarthritis
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Arthritis
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Sinus Problems
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Compartment Syndrome
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Hereditary/Congenital Deformity
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Osteomalacia
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Artificial Joints / Special Equipment
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Baker's Cyst
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Spasms / Cramps
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Degenerative Disk Disease
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Jaw Pain (TMJD)
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Osteoporosis
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Bone Disease
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Spondylolisthesis
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Dislocation
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Joint Injury
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Paget Disease
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Bone or Joint Disease
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Strain/Sprain
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Plantar Fasciitis
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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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Muscular Dystrophy
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Adhesive Capsulitis
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Psoriatic Arthritis
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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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Myasthenia Gravis
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Amyotrophic Lateral Sclerosis (ALS)
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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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Osgood-Schlatter Disease
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Ankylosing Spondylitis
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Other Musculoskeletal
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Cardiovascular
Postural Orthostatic Tachycardia Syndrome
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Cardiac Arrhythmia
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Congenital Heart Defect
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Hyperlipidemia
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Raynaud Disease
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Cardiovascular Accident
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Congestive Heart Failure
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Low Blood Pressure
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Acute Coronary Syndrome
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Rheumatic Heart Disease
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Cardiovascular Conditions
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Coronary Artery Disease
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Lymphedema
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Aneurysm
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Stroke
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Chest Pain
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Fainting Spells
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Myocardial infarction
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Angina
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Swelling
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Chronic Ischemic Heart Disease
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Heart Attack
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Pacemaker
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Atherosclerosis
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Valve Disorders
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Chronic Venous Insufficiency
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Heart Condition
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Pericarditis
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Peripheral Vascular Disease
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Blood Clots
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Varicose Veins
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Cold Feet
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Heart Disease
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Phlebitis
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Blood Pressure
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Cold Hands
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High Blood Pressure
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Other Cardiovascular
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Neurological
Peripheral Neuropathy
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Stroke
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Cerebral Vascular Accident (Stroke)
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Fatigue
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Post Polio Syndrome
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Syringomyelia
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Cerebral-vascular Accident
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Fibromyalgia
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Herniated Disc
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Sciatic Pain
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Bell's Palsy
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Tethered Cord
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Cerebrospinal Fluid Leak
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Huntington Disease
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Seizure Disorder
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Brain Disorder
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Tingling
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Chiari Malformation
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Loss of Sensation
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Shingles
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Brain Injury
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Transient Ischemic Attacks (TIA)
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Chronic Pain Disorder
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Multiple Sclerosis
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Shingles / Herpes
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Burning
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Twitching of Face
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Dizziness
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Numbness
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Sleeping Disorders
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Carpal Tunnel
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Vertebral and Spinal Cord Injury
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Dural Ectasia
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Parkinsons
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Stabbing
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Cerebral Palsy
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Epilepsy
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Other Neurological
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Immune
Allergies
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Lupus
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Anaphylaxis
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Non-Hodgkin Lymphoma
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Cancer
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Rheumatoid Arthritis
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CVID
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Sjogren's Syndrome
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HIV/Aids
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Hodgkin Lymphoma
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Infectious Mononucleosis
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Leukemia
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Other Immune
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Endocrine
Acute Pancreatitis
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Temiskaming Diabetes Program
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Adrenal Fatigue
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Wound Healing Status?
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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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Prostate Condition
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Other Endocrine
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Hearing
Ear Problems
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Hearing Loss
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Meniere Disease
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Motion Sickness
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Tinnitus
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Vertigo
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Conductive Hearing Loss
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Other Hearing
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Blood
Haemophilia
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Thrombosis/Embolism
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Hepatitis
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High Cholesterol
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HIV
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Anemia
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HIV/AIDS
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Bleeding Disorder
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Hypercoagulability
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Blood Thinner Medication
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Polycythemia
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Fainting Spells
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Stroke
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Other Blood
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Gastrointestinal
Diverticulitis
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Hiatal Hernia
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Intestinal Gas/Bloating
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Irritable Bowel Syndrome
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Celiac Disease
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Ulcerative Colitis
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Constipation
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Crohn's Disease
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Diarrhea
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Digestive Conditions
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Other Gastrointestinal
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General Injury Related Questions
What is the next competition/challenge?
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Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Prenatal (check boxes to enter details below)
Due Date
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Trimester
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Weeks Pregnant
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Number of previous pregnancies/births?
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Anemia
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Blood Clot (Phlebitis)
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Miscarriage
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Nausea
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Pre-eclampsia (toxemia)
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Sciatica
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Separation of Rectus Muscle (diastasis recti)
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Separation of Symphysis Pubis
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Twins or More
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Visual Disturbances
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Previous C-Section
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Carpal Tunnel Syndrome
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Allergy to Nut Oils
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Hypoglycemia
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High Risk Pregnancy
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Massage Goals
Alternative Therapy
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Stress Relief
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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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Injury Rehabilitation
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Positive Reinforcement
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Address Health Issues
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Strength Training
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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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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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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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Physical Activities You Participate In
Golf
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Swimming
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Lacrosse
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Tennis
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Marathon
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Triathlon
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Pilates
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Weight Lifting
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Rugby
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Yoga
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Baseball
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Running
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Crossfit
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Soccer
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Football
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Softball
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Other Activities
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Number of Times of Week You Practice
Once a week
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2-4 times a week
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More than 4 times a week
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Less than a couple of times a month
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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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