Bob Holzman LMT, Orthopedic & Sports Massage
HIPAA Compliant Confidential Health History
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General Health
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Medications
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Conditions
Genetics
Ehlers-Danlos Syndromes
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Down Syndrome
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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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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Other
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Massage Goals
Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Medium Pressure Preferred
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Deep Pressure Preferred
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Health Questions
Heart Attack
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Heart Condition
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Pacemaker
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Congenital Heart Defect
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Past Heart Surgery
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Asthma
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Mood Disorder
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Concussion
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Depression
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Schizophrenia
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Epilepsy
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Stroke
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Hearing Impairment
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Vertigo
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
New Onset of Cough
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Worsening Chronic Cough
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Sore Throat
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Difficulty Swallowing
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
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Fatigue
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Chills
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Pink eye (conjunctivitis)
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Runny nose/nasal congestion without other known cause
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Sudden onset body aches
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New rash or other skin changes
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Contact with someone with COVID
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TMJ (Jaw)
Ear Stuffiness
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Clenching
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Grinding
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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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Ear Blockage
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Ear Pressure
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Ear Ringing
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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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Other
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Energy
How long do you sleep on average?
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Is your energy constant?
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Do you struggle with insomnia?
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Well Being
Smoking
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Sports
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Caffeine
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Drinking
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Exercise
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Mobility/Walking Aids
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Female Health
Menopause
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Breast Cancer
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Currently Pregnant
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Brain Disorders
Social Anxiety Disorder
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Asperger Syndrome
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Autism
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Bipolar Disorder
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Generalized Anxiety Disorder
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Obsessive Compulsive Disorder
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Panic Disorder
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Headaches
Tension
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Migraines
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Headaches
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Sinus
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Chronic Daily Headache
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Other Headaches
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Neurological
Shingles
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Dizziness
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Twitching of Face
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Multiple Sclerosis
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Epilepsy
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Spinal Cord Injury
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Huntington Disease
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Bell's Palsy
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Myasthenia Gravis
Brain Disorder
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Herniated Disc
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Tingling
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Loss of Sensation
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Burning
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Carpal Tunnel
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Numbness
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Loss of strength
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Sciatica
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Chronic Pain Disorder
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Brain Injury
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Cerebral Palsy
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Seizure Disorder
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Parkinsons
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Other Neurological
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Cardiovascular
Raynaud Disease
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Heart Attack
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Peripheral Vascular Disease
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Atherosclerosis
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Rheumatic Heart Disease
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Phlebitis / thrombosis
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Postural Orthostatic Tachycardia Syndrome
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Cardiac Arrhythmia
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Blood Clots
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Valve Disorders
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Stroke
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Chronic Ischemic Heart Disease
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Lymphedema
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Myocardial infarction
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Cardiovascular Accident
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Swelling
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Chronic Venous Insufficiency
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Varicose Veins
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Cardiovascular Conditions
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Pacemaker
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Congenital Heart Defect
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Cold Hands
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Cold Feet
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High Blood Pressure
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Chest Pain
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Acute Coronary Syndrome
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Heart Disease
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Coronary Artery Disease
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Low Blood Pressure
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Fainting Spells
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High / low Blood Pressure
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Aneurysm
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Hyperlipidemia
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Congestive Heart Failure
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Angina
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Pericarditis
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Other Cardiovascular
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Gastrointestinal
Diverticulitis
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Eating Disorder
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Hiatal Hernia
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Irritable Bowel Syndrome
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Crohn's Disease
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Intestinal Gas/Bloating
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Poor Appetite
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Digestive Conditions
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Stomach Disorder
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Celiac Disease
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Abdominal Hernia
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Constipation
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Acid Reflux
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Other Gastrointestinal
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Respiratory
Respiratory Tract Infection
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Chronic Cough
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Tuberculosis
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Sinus Problem
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COPD
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Shortness of Breath
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Cystic Fibrosis
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Asthma
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Emphysema
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Bronchitis
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Respiratory Conditions
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Other Respiratory
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Skin
Cosmetic Surgery
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Rosacea
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Psoriasis
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Eczema
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Hair Transplant
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Rash
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UV Burn
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Bruise Easily
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Infectious Skin Conditions
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Athletes Foot
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Urticaria
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Melanoma
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Chemical Burn
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Hypersensitive Reactions
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Skin Conditions
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Melanoma/Carcinoma
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Skin Irritations
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Other Skin
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Kidney
Kidney Stones
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Urinary Incontinence
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Musculoskeletal
Osgood-Schlatter Disease
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Artificial Joints / Special Equipment
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Adhesive Capsulitis
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Fibromyalgia
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Osteomalacia
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Tendonitis/Bursitis
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Baker's Cyst
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Ankylosing Spondylitis
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Ehlers-Danlos Syndrome
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Paget Disease
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Osteoarthritis
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Arthritis
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Bone or Joint Disease
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Compartment Syndrome
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Plantar Fasciitis
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Psoriatic Arthritis
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Jaw Pain (TMJD)
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Dislocation
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Spasms / Cramps
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Scleroderma
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Chronic Fatigue Syndrome
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Fracture
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Spondylolisthesis
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Scoliosis
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Osteoporosis
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Degenerative Disk Disease
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Hereditary/Congenital Deformity
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Whiplash
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Strain/Sprain
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Gout
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Sinus Problems
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Joint Stiffness / Swelling
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Joint Injury
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Muscular Dystrophy
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Other Musculoskeletal
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Blood
Blood Thinner Medication
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Hypercoagulability
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Fainting Spells
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High Cholesterol
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Stroke
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Thrombosis/Embolism
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Haemophilia
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Anemia
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Bleeding Disorder
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Other Blood
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Immune
Cancer
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Rheumatoid Arthritis
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Other Immune
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Hearing
Ear Problems
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Hearing Loss
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Other Hearing
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Endocrine
Hyperthyroidism
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Hypothyroidism
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Pituitary and Growth Disorder
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Adrenal Fatigue
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Diabetes
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Other Endocrine
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General Injury Related Questions
Previous sports-related injuries?
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Treatment of previous injury?
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Miscellaneous
Vision Problems
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Surgical Pins or Wire
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Hearing Impaired
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Upper Respiratory Infection
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Mental Health Issues
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Other Medical Conditions
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Other Diagnosed Diseases
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Physical Activities You Participate In
Softball
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Football
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Swimming
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Golf
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Tennis
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Lacrosse
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Triathlon
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Marathon
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Pilates
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Waterpolo
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Rugby
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Weight Lifting
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Running
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Yoga
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Baseball
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Soccer
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Crossfit
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Other Activities
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Allergy
Miscellaneous
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Environmental
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Skin sensitivity to particular lotion / oils
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Food
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Medical
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Emotion / Mood
Anxiety
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Confusion
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Depression
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Grief
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PTSD
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Rate the stress in your life (1-10)
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