Need Help? Call:
845 797-2176
Bob Holzman LMT, Orthopedic & Sports Massage
Need Help? Call:
845 797-2176
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Emergency Contact
Emergency Contact
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Medical Info
Primary Complaint
General Health
Source of Referral
Current Treatment
Past Treatment (from other practitioners)
Medications
Injuries
Surgeries
Additional Info
Conditions
Female Health
Menopause
Breast Cancer
Ovarian Cancer
Osteoporosis
Currently Pregnant
Implants
Pelvic Floor Injury
Pelvic Pain
Comments
Menopause
Breast Cancer
Ovarian Cancer
Osteoporosis
Currently Pregnant
Implants
Pelvic Floor Injury
Pelvic Pain
Energy
Do you struggle with insomnia?
Does your energy fluctuate?
How long do you sleep on average?
Is your energy constant?
What is your energy level upon awakening?
When is your energy highest?
When is your energy lowest?
Comments
Do you struggle with insomnia?
Does your energy fluctuate?
How long do you sleep on average?
Is your energy constant?
What is your energy level upon awakening?
When is your energy highest?
When is your energy lowest?
Feet
Bunions
Corns/Callouses
Dry/Cracked Skin
Hammer Toe
Heel Fissures
Involuted Nails (Curved/Pinched)
Itchy or Peeling Skin
Onychocryptosis (Ingrown Nail)
Onychomycosis (Nail Fungus)
Onychoptosis (Nail Loss)
Overlapping Toes
Pes Cavus (High Arch)
Pes Planus (Flat Feet)
Plantar Fasciitis
Plantar Wart
Hallux Valgus
Comments
Bunions
Corns/Callouses
Dry/Cracked Skin
Hammer Toe
Heel Fissures
Involuted Nails (Curved/Pinched)
Itchy or Peeling Skin
Onychocryptosis (Ingrown Nail)
Onychomycosis (Nail Fungus)
Onychoptosis (Nail Loss)
Overlapping Toes
Pes Cavus (High Arch)
Pes Planus (Flat Feet)
Plantar Fasciitis
Plantar Wart
Hallux Valgus
Well Being
Caffeine
Drinking
Exercise
Mobility/Walking Aids
Range of Motion
Smoking
Sports
Comments
Caffeine
Drinking
Exercise
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
Treatment Goals
Improve Symptoms
Pain Relief
Rehabilitation
Support in Healing/Recovery
Other
Health Advice for Healing
Improve Lifestyle
Improve Well Being
Stress Relief
Comments
Improve Symptoms
Pain Relief
Rehabilitation
Support in Healing/Recovery
Other
Health Advice for Healing
Improve Lifestyle
Improve Well Being
Stress Relief
Infectious
Epstein Barr
Lyme Disease
Pneumonia
Strep
Comments
Epstein Barr
Lyme Disease
Pneumonia
Strep
Genetics
Down Syndrome
Ehlers-Danlos Syndromes
Other
Comments
Down Syndrome
Ehlers-Danlos Syndromes
Other
Health Questions
Asthma
Concussion
Congenital Heart Defect
Depression
Epilepsy
Hearing Impairment
Heart Attack
Heart Condition
Mood Disorder
Pacemaker
Past Heart Surgery
Schizophrenia
Stroke
Vertigo
Comments
Asthma
Concussion
Congenital Heart Defect
Depression
Epilepsy
Hearing Impairment
Heart Attack
Heart Condition
Mood Disorder
Pacemaker
Past Heart Surgery
Schizophrenia
Stroke
Vertigo
COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Contact with someone with COVID
New Onset of Cough
Persistent Pain in Chest
Recent domestic air travel
Have you been tested for COVID?
Have you had the antibody test?
Sore Throat
Decrease or sudden loss of taste and smell
Fatigue
Chills
Nasal or sinus congestion
Sudden onset body aches
New rash or other skin changes
Contact with someone who was in contact with COVID
Recent international air travel
Recent travel to area with high infection rates
Been in group where social distancing not observed
Have you taken precautions to limit exposure
Are you considered high risk?
Spend time around anyone that is high risk
Willing to wash hands before entering clinic
Willing to wash hands before leaving clinic
Agree to wear face mask during treatment
Willing to wear face mask in the clinic
Worsening Chronic Cough
Difficulty Swallowing
Have you had a new onset of muscle aches and pain since the emergence of the virus?
Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
Contact with anyone with acute respiratory Illness
If over 70, unexplained or increase number of falls?
If over 70, acute functional decline?
If over 70, worsening of chronic conditions?
Comments
Contact with someone with COVID
New Onset of Cough
Persistent Pain in Chest
Recent domestic air travel
Have you been tested for COVID?
Have you had the antibody test?
Sore Throat
Decrease or sudden loss of taste and smell
Fatigue
Chills
Nasal or sinus congestion
Sudden onset body aches
New rash or other skin changes
Contact with someone who was in contact with COVID
Recent international air travel
Recent travel to area with high infection rates
Been in group where social distancing not observed
Have you taken precautions to limit exposure
Are you considered high risk?
Spend time around anyone that is high risk
Willing to wash hands before entering clinic
Willing to wash hands before leaving clinic
Agree to wear face mask during treatment
Willing to wear face mask in the clinic
Worsening Chronic Cough
Difficulty Swallowing
Have you had a new onset of muscle aches and pain since the emergence of the virus?
Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
Contact with anyone with acute respiratory Illness
If over 70, unexplained or increase number of falls?
If over 70, acute functional decline?
If over 70, worsening of chronic conditions?
Brain Disorders
Asperger Syndrome
Autism
Bipolar Disorder
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Panic Disorder
Sleep Disorder
Social Anxiety Disorder
Comments
Asperger Syndrome
Autism
Bipolar Disorder
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Panic Disorder
Sleep Disorder
Social Anxiety Disorder
General Injury Related Questions
Previous sports-related injuries?
Treatment of previous injury?
OTC medications
Pain medications or steroids
Surgery (type/year)
Complications from that injury?
Comments
Previous sports-related injuries?
Treatment of previous injury?
OTC medications
Pain medications or steroids
Surgery (type/year)
Complications from that injury?
Massage Goals
Balance
Flexibility
Injury Rehabilitation
Stress Relief
Date of Last Massage
Massage Frequency
Light Pressure Preferred
Medium Pressure Preferred
Other
Deep Pressure Preferred
Comments
Balance
Flexibility
Injury Rehabilitation
Stress Relief
Date of Last Massage
Massage Frequency
Light Pressure Preferred
Medium Pressure Preferred
Other
Deep Pressure Preferred
Accident Info
Date of Injury
MVA Claim
Workers Comp Claim
Comments
Date of Injury
MVA Claim
Workers Comp Claim
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
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
Other
Current Complaint
Pain Severity: 1-10
Date of Injury?
Prescription pain meds 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?
Heat Did it help?
Cold Did it help?
Immobilization Did it help?
Other creams, gels or unguents
Other therapies
Physical Activities You Participate In
Baseball
Crossfit
Football
Golf
Lacrosse
Marathon
Pilates
Rugby
Running
Soccer
Softball
Swimming
Tennis
Triathlon
Waterpolo
Weight Lifting
Yoga
Other Activities
Comments
Baseball
Crossfit
Football
Golf
Lacrosse
Marathon
Pilates
Rugby
Running
Soccer
Softball
Swimming
Tennis
Triathlon
Waterpolo
Weight Lifting
Yoga
Other Activities
Allergy
Environmental
Food
Medical
Miscellaneous
Comments
Environmental
Food
Medical
Miscellaneous
Emotion / Mood
Anxiety
Confusion
Depression
Grief
PTSD
Rate the stress in your life (1-10)
Comments
Anxiety
Confusion
Depression
Grief
PTSD
Rate the stress in your life (1-10)
Area of Complaint
Left Side of Neck
Left Side of Low Back
Left Side of Mid Back
Left Side of Upper Back
Left Shoulder
Left Arm
Left Hand
Left Hip
Left Knee
Left Ankle
Left Foot
Left Leg
Right Leg
Right Side of Upper Back
Right Foot
Right Ankle
Right Knee
Right Side of Neck
Right Side of Low Back
Right Side of Mid Back
Right Shoulder
Right Arm
Right Hand
Right Hip
Right Elbow
Left Elbow
Right Wrist
Left Wrist
Chest
Abdomen
Neck
Upper Back
Mid Back
Low Back
Left Thigh
Left Calf
Right Thigh
Right Calf
Left Gluteal
Right Gluteal
Left Groin
Right Groin
Sacrum
Tailbone (coccyx)
Comments
Left Side of Neck
Left Side of Low Back
Left Side of Mid Back
Left Side of Upper Back
Left Shoulder
Left Arm
Left Hand
Left Hip
Left Knee
Left Ankle
Left Foot
Left Leg
Right Leg
Right Side of Upper Back
Right Foot
Right Ankle
Right Knee
Right Side of Neck
Right Side of Low Back
Right Side of Mid Back
Right Shoulder
Right Arm
Right Hand
Right Hip
Right Elbow
Left Elbow
Right Wrist
Left Wrist
Chest
Abdomen
Neck
Upper Back
Mid Back
Low Back
Left Thigh
Left Calf
Right Thigh
Right Calf
Left Gluteal
Right Gluteal
Left Groin
Right Groin
Sacrum
Tailbone (coccyx)
Headaches
Migraines
Headaches
Sinus
Chronic Daily Headache
Tension
Other Headaches
Comments
Migraines
Headaches
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
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Adrenal Fatigue
Other Endocrine
Comments
Diabetes
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Adrenal Fatigue
Other Endocrine
Gastrointestinal
Digestive Conditions
Crohn's Disease
Celiac Disease
Constipation
Diverticulitis
Eating Disorder
Irritable Bowel Syndrome
Poor Appetite
Stomach Disorder
Abdominal Hernia
Acid Reflux
Other Gastrointestinal
Hiatal Hernia
Intestinal Gas/Bloating
Comments
Digestive Conditions
Crohn's Disease
Celiac Disease
Constipation
Diverticulitis
Eating Disorder
Irritable Bowel Syndrome
Poor Appetite
Stomach Disorder
Abdominal Hernia
Acid Reflux
Other Gastrointestinal
Hiatal Hernia
Intestinal Gas/Bloating
Hearing
Ear Problems
Hearing Loss
Other Hearing
Comments
Ear Problems
Hearing Loss
Other Hearing
Immune
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
Other Immune
Comments
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
Other Immune
Kidney
Electrolyte Imbalance
Kidney Stones
Urinary Incontinence
Comments
Electrolyte Imbalance
Kidney Stones
Urinary Incontinence
Musculoskeletal
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Osteoarthritis
Ankylosing Spondylitis
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Adhesive Capsulitis
Baker's Cyst
Bone or Joint Disease
Carpal Tunnel Syndrome
Chronic Fatigue Syndrome
Degenerative Disk Disease
Joint Stiffness / Swelling
Ehlers-Danlos Syndrome
Plantar Fasciitis
Spasms / Cramps
Spondylolisthesis
Whiplash
Other Musculoskeletal
Jaw Pain (TMJD)
Comments
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Osteoarthritis
Ankylosing Spondylitis
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Adhesive Capsulitis
Baker's Cyst
Bone or Joint Disease
Carpal Tunnel Syndrome
Chronic Fatigue Syndrome
Degenerative Disk Disease
Joint Stiffness / Swelling
Ehlers-Danlos Syndrome
Plantar Fasciitis
Spasms / Cramps
Spondylolisthesis
Whiplash
Other Musculoskeletal
Jaw Pain (TMJD)
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
Sciatic Pain
Bell's Palsy
Carpal Tunnel
Fatigue
Fibromyalgia
Peripheral Neuropathy
Shingles / Herpes
Twitching of Face
Other Neurological
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
Sciatic Pain
Bell's Palsy
Carpal Tunnel
Fatigue
Fibromyalgia
Peripheral Neuropathy
Shingles / Herpes
Twitching of Face
Other Neurological
Respiratory
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Other Respiratory
Sinus Problem
Comments
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Other Respiratory
Sinus Problem
Skin
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Melanoma
Bruise Easily
Acne
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Plantar's Wart
Psoriasis
Rash
UV Burn
Cosmetic Surgery
Eczema
Non-Surgical Scars
Surgical Scars
Urticaria
Hair Transplant
Rosacea
Other Skin
Comments
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Melanoma
Bruise Easily
Acne
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Plantar's Wart
Psoriasis
Rash
UV Burn
Cosmetic Surgery
Eczema
Non-Surgical Scars
Surgical Scars
Urticaria
Hair Transplant
Rosacea
Other Skin
Miscellaneous
Vision Problems
Vision Loss
Mental Health Issues
Surgical Pins or Wire
Other Diagnosed Diseases
Insomnia
Other Medical Conditions
Hearing Impaired
Upper Respiratory Infection
Comments
Vision Problems
Vision Loss
Mental Health Issues
Surgical Pins or Wire
Other Diagnosed Diseases
Insomnia
Other Medical Conditions
Hearing Impaired
Upper Respiratory Infection
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