Sana Clinical Massage
Clinical Intake Form
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Personal Info
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Emergency Contact
Emergency Contact
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Relationship
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Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
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Additional Info
Conditions
Well Being
Sports
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Water Intake
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Drinking
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Exercise
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Smoking
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Have you taken precautions to limit exposure
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Have you tested positive for COVID-19?
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Have you been tested for COVID?
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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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Difficulty Breathing
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Decrease or sudden loss of taste and smell
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Have you had a new onset of muscle aches and pain since the emergence of the virus?
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Nausea
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Vomiting
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Diarrhea
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New rash or other skin changes
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Contact with someone with COVID
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Had close contact with a confirmed case of COVID-19 without wearing PPE
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Are you in high or moderate risk groups?
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Have you been shielding?
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Contact with someone who is awaiting COVID test results.
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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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I agree to wash/sanitize my hands before and after treatment
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No COVID Symptoms
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Oncology
Cancer Type
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Date of Diagnosis
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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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Treatment: Chemotherapy
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Treatment: Radiation
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Area of Radiation
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Other Treatments
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Medical Devices
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Loss of Movement
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Current Tumour
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Treatment Goals
Other
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Female Health
Birth Control Method
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Implants
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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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Tension
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Other Headaches
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Cardiovascular
Varicose Veins
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Blood Clots
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Heart Condition
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High Blood Pressure
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Low Blood Pressure
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Lymphedema
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Raynaud Disease
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Swelling
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Other Cardiovascular
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Family History
Respiratory
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Arthritis
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Cancer
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Cardiovascular
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Diabetes
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Blood
Anemia
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Bleeding Disorder
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Blood Thinner Medication
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Haemophilia
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Hepatitis
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Stroke
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Thrombosis/Embolism
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Other Blood
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Musculoskeletal
Gout
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Whiplash
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Joint Stiffness / Swelling
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Osteoarthritis
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Plantar Fasciitis
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Scoliosis
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Arthritis
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Spasms / Cramps
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Broken Bone / Fracture
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Strain/Sprain
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Dislocation
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Tendonitis/Bursitis
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Other Musculoskeletal
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Skin
Bruise Easily
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Infectious Skin Conditions
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Non-Surgical Scars
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Surgical Scars
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Other Skin
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Endocrine
Diabetes
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Other Endocrine
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Immune
Allergies
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HIV/Aids
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Other Immune
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Neurological
Burning
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Herniated Disc
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Stabbing
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Loss of Sensation
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Numbness
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Sciatic Pain
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Tingling
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Other Neurological
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Respiratory
Other Respiratory
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Gastrointestinal
Other Gastrointestinal
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Miscellaneous
Other Medical Conditions
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Other Diagnosed Diseases
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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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Blood Clot (Phlebitis)
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Edema/Swelling
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Miscarriage
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Allergy to Nut Oils
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High Risk Pregnancy
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Massage Goals
Other
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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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Other
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Physical Activities You Participate In
Other Activities
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Allergy
Environmental
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Food
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Medical
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Miscellaneous
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Emotion / Mood
Anxiety
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Other Emotions
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