Questionnaire

Please List Any Medication (Vitamins, Herbs Or Pharmaceutical) Taken Now Or At Regular Intervals (Include Explanation Of What Medication Is Used To Treat):

Are You Currently Under The Care Of A Physician?

Please List Reason(S):

Are There Any Other Health Concerns You Wish To Discuss Today?

If Yes, Please Describe:

Are you currently experiencing any of the following conditions?

Flu or Cold

Inflammation

Fever

Infection

Contagious Disease

Please check any of the following conditions below that currently affect you or that you have experienced in the last 5 years.

Musculoskeletal

Fibromyalgia

Spasms/Cramps

Sprains/Strains

Osteoporosis

Postural Deviations

Gout

Osteoarthritisaheumatoid Arthritis

TMJ

Cysts

Bursitis

Plantar Fascitis

Tendonitis

Torticollis

Whiplash Syndrome

Carpal Tunnel Syndrome

Sciatica

Thoracic Outlet Syndrome

Headache

Leg Pain

Arm Pain/shoulder Pain

Low Back Pain

Mid Back Pain

Hip Pain

Other

Respiratory

Pneumonia

Sinusitis

Asthma

Trouble Breathing

Dizziness

Other

Circulatory

Anemia

Hemophilia

Hypertension

Low Blood Pressure

Raynaud's Disease

Varicose Veins

Heart Condition

Blood Clots/phlebitis

Diabetes

Other

Digestive

Ulcers

Irritable Bowel Syndrome

Colitis

Gallstones

Hepatitis

Crohn's Disease

Diarrhea

Gas/bloating

Indigestion

Other

Skin

Fungal Infections

Acne

Impetigo

Dermatitis/eczema

Psoriasis

Open Wound Or Sore

Rashes

Warts/moles

Athletes Foot

Other

Nervous System

ALS

Multiple Sclerosis

Parkinson's Disease

Bell's Palsy

Neuritis

Spinal Cord Injury

Stroke

Trigeminal Neuralgia

Seizure Disorders

Numbness/tingling/twitching

Other

Insomnia

Anxiety/panic Attacks

PMS

Grief Process

Cancer

Substance Abuse

Pregnancy

Chronic Fatigue

Hiv/aids

Lupus

Kidney Disease

Bladder Infection

Postoperative Situation

Edema

Other

The above information is accurate and true to the best of my knowledge. I understand that massage therapists do not diagnose disease, prescribe medications bones. I further understand that message therapy is not a substitute for medical attention or examination. I take responsibility for altering my practitioner to any physical, mental or emotional changes that occur with my health. I also understand that cancelled or missed appointment without 24 hours notice (medical emergencies excluded) may be charged in full for the price of the missed session.

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