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General Notes
Conditions
Emotion / Memory
Alzheimer Disease
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Comments
Alzheimer Disease
Anxiety Disorder
Mood Disorder
Schizophrenia
Stress
Substance Use Disorder
Prenatal (check boxes to enter details below)
Due Date
Trimester
Weeks Pregnant
Number of previous pregnancies/births?
Anemia
Leaking Amniotic Fluid
Bladder Infection
Blood Clot (Phlebitis)
Abdominal Cramping
Diabetes
Edema/Swelling
Leg Cramps
Miscarriage
Nausea
Problems with Placenta
Preterm Labour
Pre-eclampsia (toxemia)
Sciatica
Separation of Rectus Muscle (diastasis recti)
Separation of Symphysis Pubis
Twins or More
Visual Disturbances
Previous C-Section
Heart Attack
Stroke
Carpal Tunnel Syndrome
Allergy to Nut Oils
Hypoglycemia
High Risk Pregnancy
Birth Location
Doula
Placental Location
Baby's Sex
Sacral Injury
Tailbone Injury
Comments
Due Date
Trimester
Weeks Pregnant
Number of previous pregnancies/births?
Anemia
Leaking Amniotic Fluid
Bladder Infection
Blood Clot (Phlebitis)
Abdominal Cramping
Diabetes
Edema/Swelling
Leg Cramps
Miscarriage
Nausea
Problems with Placenta
Preterm Labour
Pre-eclampsia (toxemia)
Sciatica
Separation of Rectus Muscle (diastasis recti)
Separation of Symphysis Pubis
Twins or More
Visual Disturbances
Previous C-Section
Heart Attack
Stroke
Carpal Tunnel Syndrome
Allergy to Nut Oils
Hypoglycemia
High Risk Pregnancy
Birth Location
Doula
Placental Location
Baby's Sex
Sacral Injury
Tailbone Injury
Oncology
Cancer Type
Date of Diagnosis
Location
Status
Treatment: Surgery
Date of Surgery
Lymph Nodes Removed
Side Effects of Surgery
Reconstruction Date
Treatment: Chemotherapy
Number of Chemo Treatments
Side Effects of Chemo
Treatment: Radiation
Number of Radiation Treatments
Area of Radiation
Nodes Irradiated
Side Effects of Radiation
Other Treatments
Medical Devices
Nausea
Vomiting
Mouth Sores
Weight Loss
Weight Gain
Bone Pain
Adhesions
Incision
Pressure Sensitivity
Pain
Former Injuries
Loss of Movement
Abnormal Skin Sensation
Memory Problems
Edema
Low Platelet
Low White Count
Blood Clot
Excessively Warm/Cold
Lymphedema
Heart Condition
Lung Condition
Dry Skin
Fragile Skin
Radiation Skin Reaction
Hair Loss
Fatigue
Systemic Infection
Infectious Condition
Current Tumour
Enlarged Lymph Nodes
Enlarged Spleen
Enlarged Liver
Radioactivity
Comments
Cancer Type
Date of Diagnosis
Location
Status
Treatment: Surgery
Date of Surgery
Lymph Nodes Removed
Side Effects of Surgery
Reconstruction Date
Treatment: Chemotherapy
Number of Chemo Treatments
Side Effects of Chemo
Treatment: Radiation
Number of Radiation Treatments
Area of Radiation
Nodes Irradiated
Side Effects of Radiation
Other Treatments
Medical Devices
Nausea
Vomiting
Mouth Sores
Weight Loss
Weight Gain
Bone Pain
Adhesions
Incision
Pressure Sensitivity
Pain
Former Injuries
Loss of Movement
Abnormal Skin Sensation
Memory Problems
Edema
Low Platelet
Low White Count
Blood Clot
Excessively Warm/Cold
Lymphedema
Heart Condition
Lung Condition
Dry Skin
Fragile Skin
Radiation Skin Reaction
Hair Loss
Fatigue
Systemic Infection
Infectious Condition
Current Tumour
Enlarged Lymph Nodes
Enlarged Spleen
Enlarged Liver
Radioactivity
Emotion / Mood
Anger
Anxiety
Confusion
Depression
Despair
Fear
Grief
Mental Abuse History
Negative Self-Talk
Other Emotions
Overall mood and energy level
Physical Abuse History
PTSD
Rate the stress in your life (1-10)
Sadness
Stress Response and Coping Strategies
Comments
Anger
Anxiety
Confusion
Depression
Despair
Fear
Grief
Mental Abuse History
Negative Self-Talk
Other Emotions
Overall mood and energy level
Physical Abuse History
PTSD
Rate the stress in your life (1-10)
Sadness
Stress Response and Coping Strategies
Feet
Bunions
Claw Toe
Corns/Callouses
Dry/Cracked Skin
Hallux Valgus
Hammer Toe
Heel Fissures
Involuted Nails (Curved/Pinched)
Itchy or Peeling Skin
Mallet Toe
Onychauxis
Onychocryptosis (Ingrown Nail)
Onychomycosis (Nail Fungus)
Onychoptosis (Nail Loss)
Overlapping Toes
Pes Cavus (High Arch)
Pes Planus (Flat Feet)
Plantar Fasciitis
Plantar Wart
Previous Amputations
Thickened Nails
Yellow Nails
Comments
Bunions
Claw Toe
Corns/Callouses
Dry/Cracked Skin
Hallux Valgus
Hammer Toe
Heel Fissures
Involuted Nails (Curved/Pinched)
Itchy or Peeling Skin
Mallet Toe
Onychauxis
Onychocryptosis (Ingrown Nail)
Onychomycosis (Nail Fungus)
Onychoptosis (Nail Loss)
Overlapping Toes
Pes Cavus (High Arch)
Pes Planus (Flat Feet)
Plantar Fasciitis
Plantar Wart
Previous Amputations
Thickened Nails
Yellow Nails
Well Being
Caffeine
Drinking
Exercise
Flexibility
Hobbies
Interests
Mobility/Walking Aids
Range of Motion
Smoking
Sports
Comments
Caffeine
Drinking
Exercise
Flexibility
Hobbies
Interests
Mobility/Walking Aids
Range of Motion
Smoking
Sports
TMJ (Jaw)
Clenching
Clicking
Difficulty Chewing
Difficulty Opening Jaw
Ear Blockage
Ear Pressure
Ear Ringing
Ear Stuffiness
Grinding
Jaw Pain
Locking
Morning Stiffness
Comments
Clenching
Clicking
Difficulty Chewing
Difficulty Opening Jaw
Ear Blockage
Ear Pressure
Ear Ringing
Ear Stuffiness
Grinding
Jaw Pain
Locking
Morning Stiffness
Brain Disorders
Acute Stress Disorder
ADD
ADHD
Agoraphobia
Anorexia Nervosa
Antisocial Personality Disorder
Asperger Syndrome
Autism
Bipolar Disorder
Borderline Personality Disorder
Bulimia Nervosa
Claustrophobia
Depression
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Obsessive Compulsive Personality Disorder
Panic Disorder
PTSD
Schizophrenia
Sleep Disorder
Social Anxiety Disorder
Comments
Acute Stress Disorder
ADD
ADHD
Agoraphobia
Anorexia Nervosa
Antisocial Personality Disorder
Asperger Syndrome
Autism
Bipolar Disorder
Borderline Personality Disorder
Bulimia Nervosa
Claustrophobia
Depression
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Obsessive Compulsive Personality Disorder
Panic Disorder
PTSD
Schizophrenia
Sleep Disorder
Social Anxiety Disorder
Accident Info
Date of Injury
Which State?
MVA Claim
Workers Comp Claim
Crime Victim Comp.
Comments
Date of Injury
Which State?
MVA Claim
Workers Comp Claim
Crime Victim Comp.
Massage Goals
Address Health Issues
Alternative Therapy
Balance
Flexibility
Improve Fitness
Increase Well-Being
Injury Rehabilitation
Positive Reinforcement
Strength Training
Stress Relief
Date of Last Massage
Massage Frequency
Light Pressure Preferred
Medium Pressure Preferred
Other
Deep Pressure Preferred
Comments
Address Health Issues
Alternative Therapy
Balance
Flexibility
Improve Fitness
Increase Well-Being
Injury Rehabilitation
Positive Reinforcement
Strength Training
Stress Relief
Date of Last Massage
Massage Frequency
Light Pressure Preferred
Medium Pressure Preferred
Other
Deep Pressure Preferred
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
Comments
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
Treatment Goals
Health Advice for Healing
Improve Lifestyle
Improve Symptoms
Improve Well Being
Pain Relief
Rehabilitation
Stress Relief
Support in Healing/Recovery
Other
Comments
Health Advice for Healing
Improve Lifestyle
Improve Symptoms
Improve Well Being
Pain Relief
Rehabilitation
Stress Relief
Support in Healing/Recovery
Other
Allergy
Environmental
Food
Latex
Mastocytosis
MCAD
Medical
Miscellaneous
Comments
Environmental
Food
Latex
Mastocytosis
MCAD
Medical
Miscellaneous
Infectious
Epstein Barr
Lyme Disease
Pneumonia
Strep
Comments
Epstein Barr
Lyme Disease
Pneumonia
Strep
Health Questions
Asthma
Concussion
Congenital Heart Defect
Depression
Epilepsy
Hearing Impairment
Heart Attack
Heart Condition
Meniere Disease
Mood Disorder
Pacemaker
Past Heart Surgery
Schizophrenia
Stroke
Vertigo
Comments
Asthma
Concussion
Congenital Heart Defect
Depression
Epilepsy
Hearing Impairment
Heart Attack
Heart Condition
Meniere Disease
Mood Disorder
Pacemaker
Past Heart Surgery
Schizophrenia
Stroke
Vertigo
Current Complaint
Pain Severity: 1-10
Date of Injury?
Prescription pain meds Did it help?
Steroids (oral) Did it help?
Steroids (injection) Did it help?
Heat Did it help?
Cold Did it help?
Immobilization Did it help?
Other creams, gels or unguents
Other therapies
Comments
Pain Severity: 1-10
Date of Injury?
Prescription pain meds Did it help?
Steroids (oral) Did it help?
Steroids (injection) Did it help?
Heat Did it help?
Cold Did it help?
Immobilization Did it help?
Other creams, gels or unguents
Other therapies
General Injury Related Questions
What is the next competition/challenge?
Previous sports-related injuries?
Treatment of previous injury?
Physical Therapy
Chiropractic
OTC medications
Pain medications or steroids
Surgery (type/year)
Complications from that injury?
Comments
What is the next competition/challenge?
Previous sports-related injuries?
Treatment of previous injury?
Physical Therapy
Chiropractic
OTC medications
Pain medications or steroids
Surgery (type/year)
Complications from that injury?
Family History
Arthritis
Cancer
Cardiovascular
Diabetes
Respiratory
Comments
Arthritis
Cancer
Cardiovascular
Diabetes
Respiratory
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)
Comments
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)
Headaches
Chronic Daily Headache
Cluster
Headaches
Migraines
Rebound
Sinus
Tension
Other Headaches
Comments
Chronic Daily Headache
Cluster
Headaches
Migraines
Rebound
Sinus
Tension
Other Headaches
Blood
Anemia
Bleeding Disorder
Blood Thinner Medication
Fainting Spells
Haemophilia
Hepatitis
High Cholesterol
HIV
HIV/AIDS
Hypercoagulability
Polycythemia
Stroke
Thrombosis/Embolism
Other Blood
Comments
Anemia
Bleeding Disorder
Blood Thinner Medication
Fainting Spells
Haemophilia
Hepatitis
High Cholesterol
HIV
HIV/AIDS
Hypercoagulability
Polycythemia
Stroke
Thrombosis/Embolism
Other Blood
Cardiovascular
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Blood Clots
Blood Pressure
Cardiac Arrhythmia
Cardiovascular Accident
Cardiovascular Conditions
Chest Pain
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Cold Feet
Cold Hands
Congenital Heart Defect
Congestive Heart Failure
Coronary Artery Disease
Fainting Spells
Heart Attack
Heart Condition
Heart Disease
High Blood Pressure
Hyperlipidemia
Low Blood Pressure
Lymphedema
Myocardial infarction
Pacemaker
Pericarditis
Peripheral Vascular Disease
Phlebitis
Postural Orthostatic Tachycardia Syndrome
Raynaud Disease
Rheumatic Heart Disease
Stroke
Swelling
Valve Disorders
Varicose Veins
Other Cardiovascular
Comments
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Blood Clots
Blood Pressure
Cardiac Arrhythmia
Cardiovascular Accident
Cardiovascular Conditions
Chest Pain
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Cold Feet
Cold Hands
Congenital Heart Defect
Congestive Heart Failure
Coronary Artery Disease
Fainting Spells
Heart Attack
Heart Condition
Heart Disease
High Blood Pressure
Hyperlipidemia
Low Blood Pressure
Lymphedema
Myocardial infarction
Pacemaker
Pericarditis
Peripheral Vascular Disease
Phlebitis
Postural Orthostatic Tachycardia Syndrome
Raynaud Disease
Rheumatic Heart Disease
Stroke
Swelling
Valve Disorders
Varicose Veins
Other Cardiovascular
Endocrine
Blood Sugar Managed?
Diabetes
Wound Healing Status?
Comments
Blood Sugar Managed?
Diabetes
Wound Healing Status?
Immune
Allergies
Anaphylaxis
Cancer
CVID
HIV/Aids
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Lupus
Non-Hodgkin Lymphoma
Rheumatoid Arthritis
Sjogren's Syndrome
Other Immune
Comments
Allergies
Anaphylaxis
Cancer
CVID
HIV/Aids
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Lupus
Non-Hodgkin Lymphoma
Rheumatoid Arthritis
Sjogren's Syndrome
Other Immune
Musculoskeletal
Adhesive Capsulitis
Amyotrophic Lateral Sclerosis (ALS)
Ankylosing Spondylitis
Arthritis
Artificial Joints / Special Equipment
Baker's Cyst
Bone Disease
Bone or Joint Disease
Broken Bone / Fracture
Carpal Tunnel Syndrome
Chronic Fatigue Syndrome
Chronic Myofascial Pain Syndrome
Compartment Syndrome
Degenerative Disk Disease
Dislocation
Dupuytren's Contracture
Ehlers-Danlos Syndrome
Fibromyalgia
Fracture
Gout
Hereditary/Congenital Deformity
Jaw Pain (TMJD)
Joint Injury
Joint Stiffness / Swelling
Muscular Dystrophy
Myasthenia Gravis
Osgood-Schlatter Disease
Osteoarthritis
Osteomalacia
Osteoporosis
Paget Disease
Plantar Fasciitis
Psoriatic Arthritis
Recti Diastasis
Scleroderma
Scoliosis
Sinus Problems
Spasms / Cramps
Spondylolisthesis
Strain/Sprain
Temporomandbular Joint Dysfunction
Tendonitis/Bursitis
Torticollis
Whiplash
Other Musculoskeletal
Comments
Adhesive Capsulitis
Amyotrophic Lateral Sclerosis (ALS)
Ankylosing Spondylitis
Arthritis
Artificial Joints / Special Equipment
Baker's Cyst
Bone Disease
Bone or Joint Disease
Broken Bone / Fracture
Carpal Tunnel Syndrome
Chronic Fatigue Syndrome
Chronic Myofascial Pain Syndrome
Compartment Syndrome
Degenerative Disk Disease
Dislocation
Dupuytren's Contracture
Ehlers-Danlos Syndrome
Fibromyalgia
Fracture
Gout
Hereditary/Congenital Deformity
Jaw Pain (TMJD)
Joint Injury
Joint Stiffness / Swelling
Muscular Dystrophy
Myasthenia Gravis
Osgood-Schlatter Disease
Osteoarthritis
Osteomalacia
Osteoporosis
Paget Disease
Plantar Fasciitis
Psoriatic Arthritis
Recti Diastasis
Scleroderma
Scoliosis
Sinus Problems
Spasms / Cramps
Spondylolisthesis
Strain/Sprain
Temporomandbular Joint Dysfunction
Tendonitis/Bursitis
Torticollis
Whiplash
Other Musculoskeletal
Neurological
Bell's Palsy
Brain Disorder
Brain Injury
Burning
Carpal Tunnel
Cerebral Palsy
Cerebral Vascular Accident (Stroke)
Cerebral-vascular Accident
Cerebrospinal Fluid Leak
Chiari Malformation
Chronic Pain Disorder
Dizziness
Dural Ectasia
Epilepsy
Fatigue
Fibromyalgia
Herniated Disc
Huntington Disease
Loss of Sensation
Multiple Sclerosis
Numbness
Parkinsons
Peripheral Neuropathy
Post Polio Syndrome
Sciatic Pain
Seizure Disorder
Shingles
Shingles / Herpes
Sleeping Disorders
Stabbing
Stroke
Syringomyelia
Tethered Cord
Tingling
Transient Ischemic Attacks (TIA)
Twitching of Face
Vertebral and Spinal Cord Injury
Other Neurological
Comments
Bell's Palsy
Brain Disorder
Brain Injury
Burning
Carpal Tunnel
Cerebral Palsy
Cerebral Vascular Accident (Stroke)
Cerebral-vascular Accident
Cerebrospinal Fluid Leak
Chiari Malformation
Chronic Pain Disorder
Dizziness
Dural Ectasia
Epilepsy
Fatigue
Fibromyalgia
Herniated Disc
Huntington Disease
Loss of Sensation
Multiple Sclerosis
Numbness
Parkinsons
Peripheral Neuropathy
Post Polio Syndrome
Sciatic Pain
Seizure Disorder
Shingles
Shingles / Herpes
Sleeping Disorders
Stabbing
Stroke
Syringomyelia
Tethered Cord
Tingling
Transient Ischemic Attacks (TIA)
Twitching of Face
Vertebral and Spinal Cord Injury
Other Neurological
Skin
Acne
Allergic Dermatosis
Athlete's Foot
Athletes Foot
Bruise Easily
Chemical Burn
Cosmetic Surgery
Dermatographia
Eczema
Herpes
Hypersensitive Reaction
Hypersensitive Reactions
Infectious Skin Conditions
Melanoma
Melanoma/Carcinoma
Moles
Non-Surgical Scars
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
Severe Irritability
Skin Conditions
Skin Irritations
Surgical Scars
Urticaria
UV 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
Comments
Acne
Allergic Dermatosis
Athlete's Foot
Athletes Foot
Bruise Easily
Chemical Burn
Cosmetic Surgery
Dermatographia
Eczema
Herpes
Hypersensitive Reaction
Hypersensitive Reactions
Infectious Skin Conditions
Melanoma
Melanoma/Carcinoma
Moles
Non-Surgical Scars
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
Severe Irritability
Skin Conditions
Skin Irritations
Surgical Scars
Urticaria
UV 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
Miscellaneous
ADHD
Autism
Contact Lens
Dental Bridge
Dental Implants
Dentures
Hearing Impaired
Insomnia
Comments
ADHD
Autism
Contact Lens
Dental Bridge
Dental Implants
Dentures
Hearing Impaired
Insomnia
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