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Custom Body Wellness Intake revised 06/21
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 (+61)
Canada (+1)
Ireland (+353)
New Zealand (+64)
United Kingdom (+44)
United States (+1)
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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
Current Treatment
Past Treatment (from other practitioners)
Medications
Injuries
Surgeries
Additional Info
Conditions
Treatment Goals
Pain Relief
Rehabilitation
Stress Relief
Support in Healing/Recovery
Health Advice for Healing
Improve Lifestyle
Improve Symptoms
Improve Well Being
Other
Area of Complaint
Neck
Left Side of Neck
Right Side of Neck
Upper Back
Left Side of Upper Back
Right Side of Upper Back
Mid Back
Left Side of Mid Back
Right Side of Mid Back
Low Back
Left Side of Low Back
Right Side of Low Back
Chest
Abdomen
Left Arm
Right Arm
Left Shoulder
Right Shoulder
Left Elbow
Right Elbow
Left Wrist
Right Wrist
Left Hand
Right Hand
Left Leg
Left Thigh
Left Calf
Right Leg
Right Thigh
Right Calf
Left Gluteal
Right Gluteal
Left Hip
Right Hip
Left Groin
Right Groin
Left Knee
Right Knee
Left Ankle
Right Ankle
Left Foot
Right Foot
Sacrum
Tailbone (coccyx)
Massage Goals
Address Health Issues
Positive Reinforcement
Alternative Therapy
Strength Training
Balance
Stress Relief
Flexibility
Improve Fitness
Increase Well-Being
Injury Rehabilitation
Massage Frequency
Other
Feet
Hammer Toe
Thickened Nails
Heel Fissures
Yellow Nails
Itchy or Peeling Skin
Mallet Toe
Onychomycosis (Nail Fungus)
Plantar Fasciitis
Bunions
Plantar Wart
Dry/Cracked Skin
Hallux Valgus
TMJ (Jaw)
Clicking
Jaw Pain
Difficulty Chewing
Locking
Difficulty Opening Jaw
Morning Stiffness
Ear Blockage
Ear Pressure
Ear Ringing
Ear Stuffiness
Clenching
Grinding
Energy
What is your energy level upon awakening?
When is your energy highest?
When is your energy lowest?
Do you struggle with insomnia?
Does your energy fluctuate?
How long do you sleep on average?
Is your energy constant?
Emotion / Memory
Mood Disorder
Schizophrenia
Stress
Substance Use Disorder
Alzheimer Disease
Anxiety Disorder
Infectious
Epstein Barr
Lyme Disease
Pneumonia
Strep
Brain Disorders
Autism
Obsessive Compulsive Disorder
Bipolar Disorder
Obsessive Compulsive Personality Disorder
Acute Stress Disorder
Borderline Personality Disorder
Panic Disorder
ADD
Bulimia Nervosa
PTSD
ADHD
Agoraphobia
Claustrophobia
Schizophrenia
Anorexia Nervosa
Depression
Sleep Disorder
Social Anxiety Disorder
Antisocial Personality Disorder
Generalized Anxiety Disorder
Asperger Syndrome
Oncology
Cancer Type
Date of Diagnosis
Location
Treatment: Surgery
Date of Surgery
Headaches
Sinus
Tension
Chronic Daily Headache
Cluster
Headaches
Migraines
Rebound
Other Headaches
Skin
Moles
Skin Conditions
Cosmetic Surgery
Non-Surgical Scars
Skin Irritations
Eczema
Pigmentary Disorder
Surgical Scars
Acne
Herpes
Plantar's Wart
UV Burn
Allergic Dermatosis
Hypersensitive Reaction
Psoriasis
Athlete's Foot
Hypersensitive Reactions
Rash
Athletes Foot
Infectious Skin Conditions
Rosacea
Bruise Easily
Melanoma
Melanoma/Carcinoma
Severe Irritability
Chemical Burn
Allergic to Iodine
Combination Skin
Dry Skin
Oily Skin
Mature Skin
Sensitive Skin
Sun Damage
Using ALPHA Hydroxy Acids
Using RETIN A
Other Skin
Respiratory
Cystic Fibrosis
Tuberculosis
Emphysema
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
Asthma
Shortness of Breath
Bronchitis
Chronic Cough
Sinus Problem
COPD
Other Respiratory
Neurological
Bell's Palsy
Tethered Cord
Herniated Disc
Sciatic Pain
Brain Disorder
Chiari Malformation
Huntington Disease
Seizure Disorder
Shingles
Brain Injury
Transient Ischemic Attacks (TIA)
Chronic Pain Disorder
Loss of Sensation
Shingles / Herpes
Twitching of Face
Dizziness
Multiple Sclerosis
Sleeping Disorders
Carpal Tunnel
Vertebral and Spinal Cord Injury
Dural Ectasia
Cerebral Palsy
Epilepsy
Parkinsons
Stroke
Cerebral Vascular Accident (Stroke)
Peripheral Neuropathy
Syringomyelia
Cerebral-vascular Accident
Fibromyalgia
Post Polio Syndrome
Other Neurological
Musculoskeletal
Jaw Pain (TMJD)
Osteoporosis
Baker's Cyst
Spasms / Cramps
Degenerative Disk Disease
Joint Injury
Paget Disease
Bone Disease
Spondylolisthesis
Dislocation
Dupuytren's Contracture
Joint Stiffness / Swelling
Plantar Fasciitis
Bone or Joint Disease
Strain/Sprain
Ehlers-Danlos Syndrome
Muscular Dystrophy
Psoriatic Arthritis
Broken Bone / Fracture
Fibromyalgia
Myasthenia Gravis
Amyotrophic Lateral Sclerosis (ALS)
Recti Diastasis
Carpal Tunnel Syndrome
Tendonitis/Bursitis
Fracture
Osgood-Schlatter Disease
Ankylosing Spondylitis
Scleroderma
Chronic Fatigue Syndrome
Torticollis
Whiplash
Gout
Osteoarthritis
Arthritis
Scoliosis
Chronic Myofascial Pain Syndrome
Hereditary/Congenital Deformity
Osteomalacia
Artificial Joints / Special Equipment
Sinus Problems
Compartment Syndrome
Other Musculoskeletal
Gastrointestinal
Ulcerative Colitis
Constipation
Gastroparesis
Crohn's Disease
Hiatal Hernia
Intestinal Gas/Bloating
Diarrhea
Intestinal Polyps
Digestive Conditions
Irritable Bowel Syndrome
Abdominal Hernia
Diverticulitis
Poor Appetite
Acid Reflux
Eating Disorder
Stomach Disorder
Adaptive Aids
Esophageal Disorder
Stomach Disorders
Celiac Disease
Fecal Impaction
Other Gastrointestinal
Cardiovascular
Cold Hands
High Blood Pressure
Phlebitis
Blood Pressure
Congenital Heart Defect
Hyperlipidemia
Postural Orthostatic Tachycardia Syndrome
Cardiac Arrhythmia
Cardiovascular Accident
Congestive Heart Failure
Low Blood Pressure
Raynaud Disease
Cardiovascular Conditions
Coronary Artery Disease
Lymphedema
Acute Coronary Syndrome
Rheumatic Heart Disease
Chest Pain
Fainting Spells
Myocardial infarction
Aneurysm
Stroke
Chronic Ischemic Heart Disease
Heart Attack
Pacemaker
Angina
Swelling
Valve Disorders
Chronic Venous Insufficiency
Heart Condition
Pericarditis
Atherosclerosis
Varicose Veins
Cold Feet
Heart Disease
Peripheral Vascular Disease
Blood Clots
Other Cardiovascular
Kidney
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Other Kidney
Endocrine
Prostate Condition
Acute Pancreatitis
Temiskaming Diabetes Program
Adrenal Fatigue
Wound Healing Status?
Blood Sugar Managed?
Diabetes
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Other Endocrine
Hearing
Vertigo
Conductive Hearing Loss
Ear Problems
Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Other Hearing
Reproductive
Enlarged Prostate
Prostatitis
Endometriosis
Premenstrual Syndrome
Gynaecological Conditions
Uterine Disorder
Menopause
Ovarian Cysts/Tumors
Breast Disorder
Pelvic Inflammatory Disease
Ectopic Pregnancy
Other Reproductive
Female Health
Hysterectomy
Menopause
PMS
Severe Menstrual Pain
Abnormal PAP test
Irregular Periods
Heavy Bleeding
Endometriosis
Infertility
Premenstrual Syndrome
Breast Cancer
Ovarian Cancer
Osteoporosis
Current Menopausal Concerns
Currently Pregnant
Implants
Fibroids
Uterine Polyps
Urinary Incontinence
Scar Tissue
Prenatal (check boxes to enter details below)
Due Date
Trimester
Weeks Pregnant
Number of previous pregnancies/births?
Leaking Amniotic Fluid
Abdominal Cramping
Diabetes
Edema/Swelling
Leg Cramps
Nausea
Problems with Placenta
Preterm Labour
Pre-eclampsia (toxemia)
Sciatica
Separation of Rectus Muscle (diastasis recti)
Separation of Symphysis Pubis
Twins or More
Previous C-Section
Heart Attack
Stroke
Carpal Tunnel Syndrome
Allergy to Nut Oils
Hypoglycemia
High Risk Pregnancy
Sacral Injury
Tailbone Injury
Looking for Doula
Eating Habits
Breakfast
Lunch
Dinner
Snacks
Accident Info
Date of Injury
Which State?
MVA Claim
Workers Comp Claim
Crime Victim Comp.
Which best describes what you are experiencing
Pain
Mild
Getting Worse
Ache
Moderate
Staying the Same
Tension
Disabling
Getting Better
Discomfort
Constant
Imbalance
Intermittent
Increases with Activity
Decreases with Activity
No Change
Other
Allergy
Environmental
Food
Latex
Emotion / Mood
PTSD
Rate the stress in your life (1-10)
Fear
Sadness
Mental Abuse History
Negative Self-Talk
Anger
Other Emotions
Anxiety
Confusion
Physical Abuse History
Depression
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