Julie Allinotte, Registered Massage Therapist
Intake Form 2021
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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
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Additional Info
Insurance Info
Insurer's Name
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Policy Number
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Claims / Benefit
Conditions
TMJ (Jaw)
Clenching
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Ear Ringing
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Difficulty Opening Jaw
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Jaw Pain
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Clicking
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Locking
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Difficulty Chewing
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Have you tested positive for COVID-19?
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Vocal Health
Hoarseness
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Complete Loss of Voice
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Difficulty Swallowing
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Pain
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Whiplash
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Vocal History
Vocal Injury
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Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Mid Back
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Right Side of Mid 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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Right Leg
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Left Hip
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Right Hip
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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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Headaches
Sinus
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Migraines
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Chronic Daily Headache
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Headaches
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Tension
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Rebound
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Other Headaches
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Respiratory
Chronic Cough
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Shortness of Breath
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Asthma
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Emphysema
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Bronchitis
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Tuberculosis
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Other Respiratory
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Musculoskeletal
Tendonitis/Bursitis
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Osteoporosis
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Artificial Joints / Special Equipment
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Whiplash
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Dislocation
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Osteoarthritis
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Fracture
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Joint Injury
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Scoliosis
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Arthritis
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Strain/Sprain
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Fibromyalgia
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Other Musculoskeletal
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Blood
Thrombosis/Embolism
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Anemia
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HIV/AIDS
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Hepatitis
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Other Blood
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Cardiovascular
Heart Attack
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Phlebitis
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Cardiovascular Conditions
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Pacemaker
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Cardiovascular Accident
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Heart Disease
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Varicose Veins
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Raynaud Disease
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High Blood Pressure
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Stroke
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Low Blood Pressure
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Blood Clots
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Congestive Heart Failure
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Other Cardiovascular
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Neurological
Brain Disorder
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Herniated Disc
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Brain Injury
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Stroke
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Transient Ischemic Attacks (TIA)
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Loss of Sensation
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Sciatic Pain
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Shingles
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Tingling
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Cerebral-vascular Accident
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Dizziness
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Other Neurological
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Immune
Anaphylaxis
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Lupus
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Rheumatoid Arthritis
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Allergies
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Cancer
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Other Immune
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Family History
Arthritis
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Cardiovascular
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Respiratory
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Kidney
Urinary Tract Infection
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Other Kidney
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Gastrointestinal
Crohn's Disease
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Celiac Disease
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Irritable Bowel Syndrome
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Digestive Conditions
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Other Gastrointestinal
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Hearing
Ear Problems
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Tinnitus
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Hearing Loss
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Vertigo
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Other Hearing
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Skin
Hypersensitive Reactions
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Melanoma/Carcinoma
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Skin Conditions
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Plantar's Wart
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Herpes
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Bruise Easily
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Psoriasis
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Rash
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Endocrine
Hyperthyroidism
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Diabetes
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Hypothyroidism
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Other Endocrine
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Reproductive
Gynaecological Conditions
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Other Reproductive
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Miscellaneous
Surgical Pins or Wire
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Vision Problems
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Vision Loss
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
Other prenatal concerns
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Due Date
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Edema/Swelling
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Carpal Tunnel Syndrome
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High Risk Pregnancy
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Emotion / Mood
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