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Treatment: Surgery
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Date of Diagnosis
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Status
Treatment: Surgery
Date of Surgery
Treatment: Chemotherapy
Treatment: Radiation
Medical Devices
Bone Pain
Adhesions
Pressure Sensitivity
Pain
Former Injuries
Loss of Movement
Abnormal Skin Sensation
Edema
Blood Clot
Excessively Warm/Cold
Lymphedema
Heart Condition
Lung Condition
Dry Skin
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Radiation Skin Reaction
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Systemic Infection
Infectious Condition
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Feet
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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
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Flexibility
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Exercise
Flexibility
Mobility/Walking Aids
Range of Motion
Sports
TMJ (Jaw)
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Grinding
Jaw Pain
Comments
Clenching
Clicking
Grinding
Jaw Pain
LIV/GB (Wood)
Dizziness
Eczema
Gall Stones
Headaches/Migraines
Herpes Simplex
Joints/Neck/Shoulder Pain
Muscle Cramping/Twitching
Poor Circulation
Shingles
Shoulder/Neck Tension
Teeth Clenching at Night
Tension
Comments
Dizziness
Eczema
Gall Stones
Headaches/Migraines
Herpes Simplex
Joints/Neck/Shoulder Pain
Muscle Cramping/Twitching
Poor Circulation
Shingles
Shoulder/Neck Tension
Teeth Clenching at Night
Tension
LU/LI (Metal)
Asthma/Allergies
Bronchitis
Cough with Sputum
Dry Cough
Dry Mouth/Throat/Nose
Shortness of Breath
Sinus Trouble
Skin Rashes/Hives
Comments
Asthma/Allergies
Bronchitis
Cough with Sputum
Dry Cough
Dry Mouth/Throat/Nose
Shortness of Breath
Sinus Trouble
Skin Rashes/Hives
HT/SI (Fire)
Aversion to Heat
Cysts/Tumor
Heart Palpitations
Skin Rash
Sore Throat
Comments
Aversion to Heat
Cysts/Tumor
Heart Palpitations
Skin Rash
Sore Throat
KID/UB (Water)
Bladder Problems
Decrease Bone Density
Feel Cold Easily
Hearing Problems
Lack of Bladder Control
Urinary Problems
Weakness/Pain in Lower Back
Comments
Bladder Problems
Decrease Bone Density
Feel Cold Easily
Hearing Problems
Lack of Bladder Control
Urinary Problems
Weakness/Pain in Lower Back
Treatment Goals
Improve Lifestyle
Improve Symptoms
Improve Well Being
Pain Relief
Rehabilitation
Stress Relief
Support in Healing/Recovery
Other
Comments
Improve Lifestyle
Improve Symptoms
Improve Well Being
Pain Relief
Rehabilitation
Stress Relief
Support in Healing/Recovery
Other
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Epstein Barr
Lyme Disease
Pneumonia
Strep
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Epstein Barr
Lyme Disease
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Strep
Health Questions
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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
Prenatal (check boxes to enter details below)
Due Date
Trimester
Weeks Pregnant
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
Heart Attack
Stroke
Carpal Tunnel Syndrome
Allergy to Nut Oils
Hypoglycemia
High Risk Pregnancy
Sacral Injury
Tailbone Injury
Comments
Due Date
Trimester
Weeks Pregnant
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
Heart Attack
Stroke
Carpal Tunnel Syndrome
Allergy to Nut Oils
Hypoglycemia
High Risk Pregnancy
Sacral Injury
Tailbone Injury
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
Accident Info
Date of Injury
Comments
Date of Injury
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
Allergy
Environmental
Food
Latex
Mastocytosis
MCAD
Medical
Miscellaneous
Comments
Environmental
Food
Latex
Mastocytosis
MCAD
Medical
Miscellaneous
Area of Complaint
Left Arm
Left Hand
Left Hip
Left Knee
Left Foot
Left Leg
Right Leg
Right Foot
Right Knee
Right Arm
Right Hand
Right Hip
Chest
Abdomen
Neck
Upper Back
Mid Back
Low Back
Comments
Left Arm
Left Hand
Left Hip
Left Knee
Left Foot
Left Leg
Right Leg
Right Foot
Right Knee
Right Arm
Right Hand
Right Hip
Chest
Abdomen
Neck
Upper Back
Mid Back
Low Back
Headaches
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Other Headaches
Comments
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Other Headaches
Blood
Hepatitis
HIV
Haemophilia
Thrombosis/Embolism
Anemia
Bleeding Disorder
HIV/AIDS
Hypercoagulability
Polycythemia
High Cholesterol
Blood Thinner Medication
Fainting Spells
Stroke
Other Blood
Comments
Hepatitis
HIV
Haemophilia
Thrombosis/Embolism
Anemia
Bleeding Disorder
HIV/AIDS
Hypercoagulability
Polycythemia
High Cholesterol
Blood Thinner Medication
Fainting Spells
Stroke
Other Blood
Cardiovascular
High Blood Pressure
Low Blood Pressure
Congestive Heart Failure
Heart Attack
Phlebitis
Cardiovascular Accident
Pacemaker
Heart Disease
Cardiovascular Conditions
Myocardial infarction
Varicose Veins
Blood Clots
Lymphedema
Cold Hands
Cold Feet
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Cardiac Arrhythmia
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Congenital Heart Defect
Coronary Artery Disease
Hyperlipidemia
Pericarditis
Raynaud Disease
Rheumatic Heart Disease
Valve Disorders
Blood Pressure
Chest Pain
Fainting Spells
Heart Condition
Peripheral Vascular Disease
Postural Orthostatic Tachycardia Syndrome
Stroke
Swelling
Other Cardiovascular
Comments
High Blood Pressure
Low Blood Pressure
Congestive Heart Failure
Heart Attack
Phlebitis
Cardiovascular Accident
Pacemaker
Heart Disease
Cardiovascular Conditions
Myocardial infarction
Varicose Veins
Blood Clots
Lymphedema
Cold Hands
Cold Feet
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Cardiac Arrhythmia
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Congenital Heart Defect
Coronary Artery Disease
Hyperlipidemia
Pericarditis
Raynaud Disease
Rheumatic Heart Disease
Valve Disorders
Blood Pressure
Chest Pain
Fainting Spells
Heart Condition
Peripheral Vascular Disease
Postural Orthostatic Tachycardia Syndrome
Stroke
Swelling
Other Cardiovascular
Endocrine
Diabetes
Acute Pancreatitis
Pituitary and Growth Disorder
Prostate Condition
Adrenal Fatigue
Blood Sugar Managed?
Temiskaming Diabetes Program
Wound Healing Status?
Other Endocrine
Comments
Diabetes
Acute Pancreatitis
Pituitary and Growth Disorder
Prostate Condition
Adrenal Fatigue
Blood Sugar Managed?
Temiskaming Diabetes Program
Wound Healing Status?
Other Endocrine
Hearing
Ear Problems
Hearing Loss
Conductive Hearing Loss
Other Hearing
Comments
Ear Problems
Hearing Loss
Conductive Hearing Loss
Other Hearing
Immune
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
HIV/Aids
Other Immune
Comments
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
HIV/Aids
Other Immune
Kidney
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Other Kidney
Comments
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Other Kidney
Musculoskeletal
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Jaw Pain (TMJD)
Osteoarthritis
Ankylosing Spondylitis
Bone Disease
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Amyotrophic Lateral Sclerosis (ALS)
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Adhesive Capsulitis
Baker's Cyst
Bone or Joint Disease
Broken Bone / Fracture
Carpal Tunnel Syndrome
Chronic Fatigue Syndrome
Chronic Myofascial Pain Syndrome
Degenerative Disk Disease
Dupuytren's Contracture
Ehlers-Danlos Syndrome
Joint Stiffness / Swelling
Plantar Fasciitis
Recti Diastasis
Spasms / Cramps
Spondylolisthesis
Temporomandibular Joint Dysfunction
Torticollis
Whiplash
Other Musculoskeletal
Comments
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Jaw Pain (TMJD)
Osteoarthritis
Ankylosing Spondylitis
Bone Disease
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Amyotrophic Lateral Sclerosis (ALS)
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Adhesive Capsulitis
Baker's Cyst
Bone or Joint Disease
Broken Bone / Fracture
Carpal Tunnel Syndrome
Chronic Fatigue Syndrome
Chronic Myofascial Pain Syndrome
Degenerative Disk Disease
Dupuytren's Contracture
Ehlers-Danlos Syndrome
Joint Stiffness / Swelling
Plantar Fasciitis
Recti Diastasis
Spasms / Cramps
Spondylolisthesis
Temporomandibular Joint Dysfunction
Torticollis
Whiplash
Other Musculoskeletal
Neurological
Stroke
Loss of Sensation
Epilepsy
Cerebral-vascular Accident
Shingles
Dizziness
Cerebral Palsy
Parkinsons
Herniated Disc
Multiple Sclerosis
Numbness
Burning
Tingling
Stabbing
Vertebral and Spinal Cord Injury
Huntington Disease
Brain Disorder
Chronic Pain Disorder
Brain Injury
Cerebral Vascular Accident (Stroke)
Seizure Disorder
Transient Ischemic Attacks (TIA)
Sciatic Pain
Bell's Palsy
Carpal Tunnel
Cerebrospinal Fluid Leak
Fatigue
Fibromyalgia
Peripheral Neuropathy
Post Polio Syndrome
Shingles / Herpes
Comments
Stroke
Loss of Sensation
Epilepsy
Cerebral-vascular Accident
Shingles
Dizziness
Cerebral Palsy
Parkinsons
Herniated Disc
Multiple Sclerosis
Numbness
Burning
Tingling
Stabbing
Vertebral and Spinal Cord Injury
Huntington Disease
Brain Disorder
Chronic Pain Disorder
Brain Injury
Cerebral Vascular Accident (Stroke)
Seizure Disorder
Transient Ischemic Attacks (TIA)
Sciatic Pain
Bell's Palsy
Carpal Tunnel
Cerebrospinal Fluid Leak
Fatigue
Fibromyalgia
Peripheral Neuropathy
Post Polio Syndrome
Shingles / Herpes
Reproductive
Pregnancy
Ovarian Cysts/Tumors
Comments
Pregnancy
Ovarian Cysts/Tumors
Respiratory
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Sinus Problem
Other Respiratory
Comments
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Sinus Problem
Other Respiratory
Skin
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Hypersensitive Reaction
Athlete's Foot
Melanoma
Bruise Easily
Acne
Allergic Dermatosis
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
UV Burn
Eczema
Severe Irritability
Urticaria
Sun Damage
Comments
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Hypersensitive Reaction
Athlete's Foot
Melanoma
Bruise Easily
Acne
Allergic Dermatosis
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
UV Burn
Eczema
Severe Irritability
Urticaria
Sun Damage
Miscellaneous
Vision Problems
Vision Loss
Surgical Pins or Wire
Other Diagnosed Diseases
Other Medical Conditions
Hearing Impaired
Liver Disease
Music Preference
Upper Respiratory Infection
Visually Impaired
Comments
Vision Problems
Vision Loss
Surgical Pins or Wire
Other Diagnosed Diseases
Other Medical Conditions
Hearing Impaired
Liver Disease
Music Preference
Upper Respiratory Infection
Visually Impaired
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