Custom Body Wellness Intake revised 06/21
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Other
Medical Info
Primary Complaint
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
Treatment Goals
Pain Relief
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Rehabilitation
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Stress Relief
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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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Other
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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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Massage Goals
Address Health Issues
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Positive Reinforcement
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Alternative Therapy
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Strength Training
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Balance
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Stress Relief
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Flexibility
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Improve Fitness
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Increase Well-Being
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Injury Rehabilitation
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Massage Frequency
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Other
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Feet
Hammer Toe
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Thickened Nails
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Heel Fissures
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Yellow Nails
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Itchy or Peeling Skin
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Mallet Toe
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Onychomycosis (Nail Fungus)
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Plantar Fasciitis
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Bunions
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Plantar Wart
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Dry/Cracked Skin
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Hallux Valgus
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TMJ (Jaw)
Clicking
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Jaw Pain
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Difficulty Chewing
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Locking
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Difficulty Opening Jaw
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Morning Stiffness
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Ear Blockage
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Ear Pressure
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Ear Ringing
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Ear Stuffiness
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Clenching
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Grinding
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Energy
What is your energy level upon awakening?
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When is your energy highest?
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When is your energy lowest?
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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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Is your energy constant?
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Emotion / Memory
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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Anxiety Disorder
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Infectious
Epstein Barr
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Lyme Disease
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Pneumonia
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Strep
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Brain Disorders
Autism
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Obsessive Compulsive Disorder
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Bipolar Disorder
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Obsessive Compulsive Personality Disorder
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Acute Stress Disorder
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Borderline Personality Disorder
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Panic Disorder
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ADD
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Bulimia Nervosa
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PTSD
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ADHD
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Agoraphobia
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Claustrophobia
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Schizophrenia
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Anorexia Nervosa
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Depression
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Sleep Disorder
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Social Anxiety Disorder
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Antisocial Personality Disorder
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Generalized Anxiety Disorder
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Asperger Syndrome
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Treatment: Surgery
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Date of Surgery
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Headaches
Sinus
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Tension
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Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Rebound
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Other Headaches
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Skin
Moles
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Skin Conditions
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Cosmetic Surgery
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Non-Surgical Scars
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Skin Irritations
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Eczema
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Pigmentary Disorder
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Surgical Scars
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Acne
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Herpes
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Plantar's Wart
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UV Burn
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Allergic Dermatosis
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Hypersensitive Reaction
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Psoriasis
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Athlete's Foot
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Hypersensitive Reactions
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Rash
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Athletes Foot
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Infectious Skin Conditions
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Rosacea
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Bruise Easily
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Melanoma
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Melanoma/Carcinoma
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Severe Irritability
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Chemical Burn
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Allergic to Iodine
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Combination Skin
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Dry Skin
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Oily Skin
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Mature Skin
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Sensitive Skin
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Sun Damage
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Using ALPHA Hydroxy Acids
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Using RETIN A
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Other Skin
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Respiratory
Cystic Fibrosis
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Tuberculosis
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Emphysema
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Infectious Respiratory Conditions
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Respiratory Conditions
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Respiratory Tract Infection
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Asthma
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Shortness of Breath
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Bronchitis
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Chronic Cough
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Sinus Problem
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COPD
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Other Respiratory
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Neurological
Bell's Palsy
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Tethered Cord
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Herniated Disc
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Sciatic Pain
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Brain Disorder
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Chiari Malformation
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Huntington Disease
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Seizure Disorder
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Shingles
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Brain Injury
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Transient Ischemic Attacks (TIA)
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Chronic Pain Disorder
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Loss of Sensation
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Shingles / Herpes
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Twitching of Face
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Dizziness
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Multiple Sclerosis
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Sleeping Disorders
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Carpal Tunnel
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Vertebral and Spinal Cord Injury
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Dural Ectasia
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Cerebral Palsy
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Epilepsy
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Parkinsons
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Stroke
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Cerebral Vascular Accident (Stroke)
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Peripheral Neuropathy
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Syringomyelia
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Cerebral-vascular Accident
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Fibromyalgia
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Post Polio Syndrome
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Other Neurological
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Musculoskeletal
Jaw Pain (TMJD)
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Osteoporosis
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Baker's Cyst
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Spasms / Cramps
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Degenerative Disk Disease
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Joint Injury
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Paget Disease
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Bone Disease
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Spondylolisthesis
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Dislocation
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Plantar Fasciitis
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Bone or Joint Disease
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Strain/Sprain
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Ehlers-Danlos Syndrome
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Muscular Dystrophy
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Psoriatic Arthritis
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Broken Bone / Fracture
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Fibromyalgia
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Myasthenia Gravis
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Amyotrophic Lateral Sclerosis (ALS)
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Recti Diastasis
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Fracture
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Osgood-Schlatter Disease
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Ankylosing Spondylitis
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Scleroderma
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Chronic Fatigue Syndrome
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Torticollis
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Whiplash
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Gout
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Osteoarthritis
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Arthritis
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Scoliosis
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Chronic Myofascial Pain Syndrome
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Hereditary/Congenital Deformity
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Osteomalacia
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Artificial Joints / Special Equipment
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Sinus Problems
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Compartment Syndrome
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Other Musculoskeletal
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Gastrointestinal
Ulcerative Colitis
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Constipation
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Gastroparesis
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Crohn's Disease
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Hiatal Hernia
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Intestinal Gas/Bloating
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Diarrhea
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Intestinal Polyps
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Digestive Conditions
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Irritable Bowel Syndrome
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Abdominal Hernia
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Diverticulitis
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Poor Appetite
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Acid Reflux
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Eating Disorder
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Stomach Disorder
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Adaptive Aids
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Esophageal Disorder
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Stomach Disorders
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Celiac Disease
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Fecal Impaction
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Other Gastrointestinal
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Cardiovascular
Cold Hands
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High Blood Pressure
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Phlebitis
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Blood Pressure
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Congenital Heart Defect
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Hyperlipidemia
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Postural Orthostatic Tachycardia Syndrome
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Cardiac Arrhythmia
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Cardiovascular Accident
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Congestive Heart Failure
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Low Blood Pressure
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Raynaud Disease
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Cardiovascular Conditions
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Coronary Artery Disease
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Lymphedema
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Acute Coronary Syndrome
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Rheumatic Heart Disease
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Chest Pain
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Fainting Spells
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Myocardial infarction
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Aneurysm
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Stroke
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Chronic Ischemic Heart Disease
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Heart Attack
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Pacemaker
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Angina
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Swelling
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Valve Disorders
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Chronic Venous Insufficiency
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Heart Condition
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Pericarditis
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Atherosclerosis
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Varicose Veins
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Cold Feet
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Heart Disease
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Peripheral Vascular Disease
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Blood Clots
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Other Cardiovascular
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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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Other Kidney
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Endocrine
Prostate Condition
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Acute Pancreatitis
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Temiskaming Diabetes Program
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Adrenal Fatigue
Characters:
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Wound Healing Status?
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Blood Sugar Managed?
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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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Other Endocrine
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Hearing
Vertigo
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Conductive Hearing Loss
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Ear Problems
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Hearing Loss
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Meniere Disease
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Motion Sickness
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Tinnitus
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Other Hearing
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Reproductive
Enlarged Prostate
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Prostatitis
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Endometriosis
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Premenstrual Syndrome
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Gynaecological Conditions
Characters:
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Uterine Disorder
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Menopause
Characters:
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Ovarian Cysts/Tumors
Characters:
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Breast Disorder
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Pelvic Inflammatory Disease
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Ectopic Pregnancy
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Other Reproductive
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Female Health
Hysterectomy
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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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Previous C-Section
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