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Custom Body Wellness Intake revised 06/21
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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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Left Side of Low Back
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Right Side of Low Back
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Chest
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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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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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Feet
Hammer Toe
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Thickened Nails
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Plantar Fasciitis
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Bunions
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What is your energy level upon awakening?
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Mature Skin
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Sun Damage
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Using ALPHA Hydroxy Acids
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Brain Disorder
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Huntington Disease
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Shingles
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Brain Injury
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Shingles / Herpes
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Multiple Sclerosis
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Sleeping Disorders
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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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Syringomyelia
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Fibromyalgia
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Post Polio Syndrome
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Musculoskeletal
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Osteoporosis
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Baker's Cyst
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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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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
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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
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Uterine Disorder
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Menopause
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Ovarian Cysts/Tumors
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Breast Disorder
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Pelvic Inflammatory Disease
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Ectopic Pregnancy
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Female Health
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Prenatal (check boxes to enter details below)
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Number of previous pregnancies/births?
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Leaking Amniotic Fluid
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Preterm Labour
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Pre-eclampsia (toxemia)
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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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Heart Attack
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Stroke
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Carpal Tunnel Syndrome
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Allergy to Nut Oils
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Hypoglycemia
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High Risk Pregnancy
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Sacral Injury
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Tailbone Injury
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Looking for Doula
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Eating Habits
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Accident Info
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Which State?
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MVA Claim
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Workers Comp Claim
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Crime Victim Comp.
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Which best describes what you are experiencing
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Staying the Same
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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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No Change
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Mental Abuse History
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Physical Abuse History
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