Alexa Cunningham's Clinic
Massage Therapy Intake Form
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Personal Info
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Emergency Contact
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Relationship
Tell Me About Yourself
Energy Level
Fatigue
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High
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Low
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Agitated
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TMJ
Clenching
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Ear Blockage
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Difficulty Chewing
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Difficulty Opening
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Jaw Pain
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Health Questions
Congenital Heart Defect
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Depression
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Diabetes
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Epilepsy
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Gastrointestinal
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Hearing Impairment
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Heart Attack
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Heart Condition
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High blood pressure
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HIV/Aids
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Low blood pressure
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Migraines/Headaches
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Mood Disorder
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Pacemaker
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Past Heart Surgery
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Stroke
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aricose veins
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Vertigo
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Asthma
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Blood thinner medication
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Cancer
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Cardiovascular
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Concussion
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Treatment Goals
Improve Well Being
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Stress Relief
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Improve Lifestyle
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Pain Relief
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Support in Healing/Recovery
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Improve Symptoms
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Rehabilitation
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Health Advice for Healing
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Other
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Well Being
Exercise
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Supplements
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Interests
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Water Intake
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Are you currently taking any supplements/Natraceuticals?
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Caffeine
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Emotion / Memory
Anxiety Disorder
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Stress
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SP/ST (Earth)
Abdominal Pain
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Indigestion/Heartburn
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Diarrhea
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Muscles Feel Tired Often
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Edema (Swelling)
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Nausea/Vomiting
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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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Female Health
Menopause
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Osteoporosis
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Currently Pregnant
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
To the best of your knowledge, within the last 14 days have you or any other member of your household or support bubble has been exposed to anyone diagnosed with COVID-19 or experiencing COVID?
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Have you taken precautions to limit exposure
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Within the last 14 days, have you tested positive for COVID-19 or experienced any COVID-19 symptoms?
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Have you tested positive for COVID-19?
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Infectious
Presence of any infectious condition?
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Area of Complaint
Neck
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Low Back
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Left Leg
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Right Hip
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Upper Back
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Left Shoulder
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Right Leg
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Sacrum
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Mid Back
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Right Shoulder
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Left Hip
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Cardiovascular
Blood Pressure
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High Blood Pressure
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Heart Condition
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Heart Disease
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Low Blood Pressure
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Allergy
Sensitive to scents/essential oils
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Other Allergies
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