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Emergency Contact
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Relationship
Doctor
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Medical Info
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General Health
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Medications
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Additional Info
Conditions
Energy
Does your energy fluctuate?
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Is your energy constant?
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When is your energy highest?
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When is your energy lowest?
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What is your energy level upon awakening?
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How long do you sleep on average?
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Do you struggle with insomnia?
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Male Health
Family History of Prostate Cancer
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Difficulty Experiencing Orgasm
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Difficulty Maintaining Erection
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Difficulty Obtaining Erection
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History of Back Injury
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Family History of Prostate Disease
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Well Being
Exercise
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Sports
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Flexibility
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Range of Motion
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Drinking
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Hobbies
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Schizophrenia
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Substance Use Disorder
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Yoga
Have Practiced Yoga
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How Often?
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Oncology
Cancer Type
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Status
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Treatment: Chemotherapy
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Treatment: Radiation
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Medical Devices
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Vocal Health
Vocal Fatigue
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Hoarseness
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Complete Loss of Voice
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Loss of Vocal Range
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Difficulty Swallowing
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Difficultly Speaking
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Difficulty Singing
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Pain
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Medications
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Whiplash
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Vocal History
Otolaryngologist
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Speech Path/Voice Teacher
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Vocal Injury
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Vocal Surgery
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Diagnosis of Vocal Injury
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Currently Performing
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Female Health
Menstrual Cramping
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Osteoporosis
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Current Menopausal Concerns
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Currently Pregnant
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Fibroids
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Pelvic Pain
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Pain with Sex
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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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Headaches
Chronic Daily Headache
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Tension
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Migraines
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Sinus
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Other Headaches
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Immune
Rheumatoid Arthritis
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Anaphylaxis
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Infectious Mononucleosis
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Allergies
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Cardiovascular
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Blood Clots
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High Blood Pressure
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Varicose Veins
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Neurological
Seizure Disorder
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Epilepsy
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Numbness
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Burning
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Tingling
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Loss of Sensation
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Vertebral and Spinal Cord Injury
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Stabbing
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Herniated Disc
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Chronic Pain Disorder
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Brain Injury
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Peripheral Neuropathy
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Sciatic Pain
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Other Neurological
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Musculoskeletal
Sinus Problems
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Hereditary/Congenital Deformity
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Gout
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Dupuytren's Contracture
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Scoliosis
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Joint Injury
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Tendonitis/Bursitis
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Torticollis
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Chronic Myofascial Pain Syndrome
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Strain/Sprain
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Arthritis
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Osgood-Schlatter Disease
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Baker's Cyst
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Chronic Fatigue Syndrome
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Amyotrophic Lateral Sclerosis (ALS)
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Ankylosing Spondylitis
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Fibromyalgia
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Osteomalacia
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Jaw Pain (TMJD)
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Recti Diastasis
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Spondylolisthesis
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Muscular Dystrophy
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Osteoporosis
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Bone Disease
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Paget Disease
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Carpal Tunnel Syndrome
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Ehlers-Danlos Syndrome
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Myasthenia Gravis
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Artificial Joints / Special Equipment
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Compartment Syndrome
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Psoriatic Arthritis
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Dislocation
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Temporomandibular Joint Dysfunction
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Scleroderma
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Whiplash
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Fracture
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Degenerative Disk Disease
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Plantar Fasciitis
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Osteoarthritis
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Other Musculoskeletal
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Skin
Herpes
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Melanoma/Carcinoma
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Psoriasis
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Rash
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Rosacea
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Acne
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UV Burn
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Athlete's Foot
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Allergic Dermatosis
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Eczema
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Infectious Skin Conditions
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Athletes Foot
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Bruise Easily
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Chemical Burn
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Other Skin
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Reproductive
Prostatitis
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Ectopic Pregnancy
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Pregnancy
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Enlarged Prostate
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Premenstrual Syndrome
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Other Reproductive
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Endocrine
Hypothyroidism
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Prostate Condition
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Blood Sugar Managed?
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Diabetes
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Hyperthyroidism
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Other Endocrine
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Respiratory
Tuberculosis
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Chronic Cough
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Shortness of Breath
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Asthma
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COPD
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Emphysema
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Bronchitis
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Infectious Respiratory Conditions
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Other Respiratory
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Gastrointestinal
Constipation
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Eating Disorder
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Digestive Conditions
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Esophageal Disorder
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Fecal Impaction
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Irritable Bowel Syndrome
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Poor Appetite
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Other Gastrointestinal
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Kidney
Kidney Stones
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Other Kidney
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Hearing
Motion Sickness
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Tinnitus
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Vertigo
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Ear Problems
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Hearing Loss
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Other Hearing
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Miscellaneous
Insomnia
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Vision Problems
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Upper Respiratory Infection
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Weakened Immune Function
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Music Preference
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Surgical Pins or Wire
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Other Medical Conditions
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Massage Goals
Address Health Issues
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Strength Training
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Alternative Therapy
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Stress Relief
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Balance
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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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Positive Reinforcement
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Massage Frequency
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Other
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Accident Info
Date of Injury
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Which best describes what you are experiencing
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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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No Change
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Other
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Emotion / Mood
Depression
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Grief
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Negative Self-Talk
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Anger
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PTSD
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Stress Response and Coping Strategies
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Physical Abuse History
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