BODY EFFECTS WELLNESS, PLLC
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General Health
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Claims / Benefit
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Pacemaker
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Congenital Heart Defect
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Depression
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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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Treatment Goals
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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Rehabilitation
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Stress Relief
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Other
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Feet
Heel Fissures
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Pes Cavus (High Arch)
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Pes Planus (Flat Feet)
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Plantar Fasciitis
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Infectious
Strep
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Epstein Barr
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Lyme Disease
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Pneumonia
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TMJ (Jaw)
Clenching
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Locking
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Clicking
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Morning Stiffness
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Difficulty Chewing
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Difficulty Opening Jaw
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Ear Pressure
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Ear Ringing
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Grinding
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Jaw Pain
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Emotion / Memory
Anxiety Disorder
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Mood Disorder
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Schizophrenia
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Stress
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Substance Use Disorder
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Alzheimer Disease
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Male Health
Family History of Prostate Cancer
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Family History of Prostate Disease
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History of Back Injury
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Painful Urination
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PSA Test Results
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Urinary Stream Changes
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Well Being
Mobility/Walking Aids
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Range of Motion
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Caffeine
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Smoking
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Sports
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Drinking
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Exercise
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Flexibility
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Hobbies
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Interests
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Female Health
Hysterectomy
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Menopause
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PMS
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Severe Menstrual Pain
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Last Period
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Number of Pregnancies
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Number of Live Births
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Abnormal PAP test
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Irregular Periods
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Menstrual Cramping
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Heavy Bleeding
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Endometriosis
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Infertility
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Unwanted hair growth
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Premenstrual Syndrome
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Breast Cancer
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Ovarian Cancer
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Osteoporosis
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Current Menopausal Concerns
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Currently Pregnant
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Implants
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Fibroids
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PCOS
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Spotting
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Dark Blood
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Clots
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Brown Spotting
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Pencil Like Stool
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Heaviness in Pelvis
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Urinary Incontinence
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Pelvic Organ Prolapse
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Pelvic Floor Injury
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Scar Tissue
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Pelvic Pain
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Pain with Sex
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Energy
Do you struggle with insomnia?
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Does your energy fluctuate?
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How long do you sleep on average?
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Vocal Health
Vocal Fatigue
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Hoarseness
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Loss of Vocal Range
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Difficulty Swallowing
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Difficultly Speaking
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Difficulty Singing
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Oncology
Cancer Type
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Date of Diagnosis
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Treatment: Surgery
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Date of Surgery
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Side Effects of Surgery
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Treatment: Chemotherapy
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Number of Chemo Treatments
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Area of Radiation
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Nodes Irradiated
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Side Effects of Radiation
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Other Treatments
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Medical Devices
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Nausea
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Vomiting
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Weight Loss
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Weight Gain
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Bone Pain
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Adhesions
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Incision
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Pressure Sensitivity
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Pain
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Former Injuries
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Loss of Movement
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Abnormal Skin Sensation
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Memory Problems
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Edema
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Blood Clot
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Excessively Warm/Cold
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Lymphedema
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Heart Condition
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Lung Condition
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Dry Skin
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Fragile Skin
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Radiation Skin Reaction
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Fatigue
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Systemic Infection
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Infectious Condition
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Current Tumour
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Radioactivity
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Vocal History
Speech Path/Voice Teacher
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Vocal Surgery
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Currently Performing
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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
Migraines
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Headaches
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Cluster
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Rebound
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Sinus
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Chronic Daily Headache
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Tension
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Other Headaches
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Brain Disorders
Acute Stress Disorder
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Depression
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PTSD
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Sleep Disorder
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Neurological
Brain Injury
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Sleeping Disorders
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Multiple Sclerosis
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Tingling
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Cerebral Vascular Accident (Stroke)
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Cerebral-vascular Accident
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Stabbing
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Seizure Disorder
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Sciatic Pain
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Stroke
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Loss of Sensation
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Transient Ischemic Attacks (TIA)
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Vertebral and Spinal Cord Injury
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Epilepsy
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Shingles
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Bell's Palsy
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Cerebral Palsy
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Huntington Disease
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Brain Disorder
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Dizziness
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Carpal Tunnel
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Parkinsons
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Numbness
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Chronic Pain Disorder
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Fibromyalgia
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Herniated Disc
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Burning
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Hearing
Conductive Hearing Loss
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Meniere Disease
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Motion Sickness
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Tinnitus
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Ear Problems
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Vertigo
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Hearing Loss
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Blood
Hypercoagulability
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Hepatitis
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Polycythemia
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Haemophilia
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HIV
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Thrombosis/Embolism
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Blood Thinner Medication
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Stroke
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Anemia
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High Cholesterol
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Bleeding Disorder
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HIV/AIDS
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Gastrointestinal
Digestive Conditions
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Constipation
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Poor Appetite
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Diarrhea
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Crohn's Disease
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Stomach Disorder
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Diverticulitis
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Ulcerative Colitis
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Eating Disorder
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Esophageal Disorder
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Fecal Impaction
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Celiac Disease
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Intestinal Polyps
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Irritable Bowel Syndrome
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Musculoskeletal
Chronic Myofascial Pain Syndrome
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Hereditary/Congenital Deformity
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Strain/Sprain
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Joint Stiffness / Swelling
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Joint Injury
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Amyotrophic Lateral Sclerosis (ALS)
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Osteoporosis
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Plantar Fasciitis
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Osgood-Schlatter Disease
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Osteoarthritis
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Muscular Dystrophy
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Gout
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Spasms / Cramps
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Ankylosing Spondylitis
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Osteomalacia
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Myasthenia Gravis
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Whiplash
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Tendonitis/Bursitis
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Bone Disease
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Sinus Problems
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Paget Disease
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Artificial Joints / Special Equipment
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Compartment Syndrome
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Psoriatic Arthritis
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Bone or Joint Disease
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Dislocation
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Fibromyalgia
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Scleroderma
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Arthritis
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Carpal Tunnel Syndrome
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Jaw Pain (TMJD)
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Fracture
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Scoliosis
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Kidney
Renal Cysts
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Urinary Incontinence
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Urinary Tract Infection
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Bladder Disorder
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Chronic Kidney Disease
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Congenital Kidney Disease
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Electrolyte Imbalance
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Kidney Stones
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Skin
Athlete's Foot
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Acne
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Psoriasis
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Allergic Dermatosis
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Rash
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Rosacea
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Herpes
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Hypersensitive Reaction
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Cosmetic Surgery
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Athletes Foot
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Bruise Easily
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UV Burn
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Eczema
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Chemical Burn
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Melanoma
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Hypersensitive Reactions
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Melanoma/Carcinoma
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Infectious Skin Conditions
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Pigmentary Disorder
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Skin Conditions
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Skin Irritations
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Plantar's Wart
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Other Skin
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Reproductive
Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Pregnancy
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Premenstrual Syndrome
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Breast Disorder
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Gynaecological Conditions
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Uterine Disorder
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Ectopic Pregnancy
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Endometriosis
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Menopause
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Immune
Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Anaphylaxis
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Allergies
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Lupus
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HIV/Aids
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Hodgkin Lymphoma
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Cancer
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Infectious Mononucleosis
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Blood Pressure
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Acute Coronary Syndrome
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Hyperlipidemia
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Angina
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Pericarditis
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Cardiovascular Accident
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Atherosclerosis
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Cold Hands
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Raynaud Disease
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Pacemaker
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Cardiac Arrhythmia
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High Blood Pressure
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Cold Feet
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Chest Pain
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Rheumatic Heart Disease
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Heart Disease
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Chronic Ischemic Heart Disease
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Low Blood Pressure
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Heart Condition
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Valve Disorders
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Myocardial infarction
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Congestive Heart Failure
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Respiratory Conditions
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Asthma
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Tuberculosis
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Emphysema
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Bronchitis
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Respiratory Tract Infection
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COPD
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Infectious Respiratory Conditions
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Cystic Fibrosis
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Endocrine
Acute Pancreatitis
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Adrenal Fatigue
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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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Family History
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Diabetes
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Cardiovascular
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Vision Loss
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Mental Health Issues
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Insomnia
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Anemia
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Diabetes
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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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Heart Attack
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Stroke
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Carpal Tunnel Syndrome
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Hypoglycemia
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High Risk Pregnancy
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Sacral Injury
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Tailbone Injury
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Massage Goals
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Address Health Issues
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Strength Training
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Alternative Therapy
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Improve Fitness
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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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Deep Pressure Preferred
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Crime Victim Comp.
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Which best describes what you are experiencing
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Getting Better
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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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No Change
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Other
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Allergy
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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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Emotion / Mood
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Rate the stress in your life (1-10)
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Stress Response and Coping Strategies
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Mental Abuse History
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Negative Self-Talk
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