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Alzheimer Disease
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Alzheimer Disease
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Hysterectomy
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Comments
Hysterectomy
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Implants
Fibroids
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Status
Treatment: Surgery
Date of Surgery
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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
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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
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Heart Condition
Lung Condition
Dry Skin
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Radiation Skin Reaction
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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
Feet
Bunions
Claw Toe
Dry/Cracked Skin
Hallux Valgus
Hammer Toe
Heel Fissures
Mallet Toe
Onychauxis
Onychomycosis (Nail Fungus)
Pes Cavus (High Arch)
Pes Planus (Flat Feet)
Plantar Fasciitis
Plantar Wart
Comments
Bunions
Claw Toe
Dry/Cracked Skin
Hallux Valgus
Hammer Toe
Heel Fissures
Mallet Toe
Onychauxis
Onychomycosis (Nail Fungus)
Pes Cavus (High Arch)
Pes Planus (Flat Feet)
Plantar Fasciitis
Plantar Wart
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
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
Infectious
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Lyme Disease
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Comments
Epstein Barr
Lyme Disease
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Ehlers-Danlos Syndromes
Loeys-Dietz Syndrome
Marfan Syndrome
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Comments
Down Syndrome
Ehlers-Danlos Syndromes
Loeys-Dietz Syndrome
Marfan Syndrome
Mitochondrial Disease
Other
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
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?
Prenatal (check boxes to enter details below)
Due Date
Trimester
Weeks Pregnant
Number of previous pregnancies/births?
Diabetes
Edema/Swelling
Leg Cramps
Nausea
Pre-eclampsia (toxemia)
Sciatica
Previous C-Section
Hypoglycemia
High Risk Pregnancy
Doula
Comments
Due Date
Trimester
Weeks Pregnant
Number of previous pregnancies/births?
Diabetes
Edema/Swelling
Leg Cramps
Nausea
Pre-eclampsia (toxemia)
Sciatica
Previous C-Section
Hypoglycemia
High Risk Pregnancy
Doula
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
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
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
Number of Times of Week You Practice
Once a week
2-4 times a week
More than 4 times a week
Less than a couple of times a month
Comments
Once a week
2-4 times a week
More than 4 times a week
Less than a couple of times a month
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
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
Family History
Arthritis
Cancer
Cardiovascular
Diabetes
Respiratory
Comments
Arthritis
Cancer
Cardiovascular
Diabetes
Respiratory
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
Acute Pancreatitis
Adrenal Fatigue
Blood Sugar Managed?
Diabetes
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Temiskaming Diabetes Program
Wound Healing Status?
Other Endocrine
Comments
Acute Pancreatitis
Adrenal Fatigue
Blood Sugar Managed?
Diabetes
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Temiskaming Diabetes Program
Wound Healing Status?
Other Endocrine
Gastrointestinal
Abdominal Hernia
Acid Reflux
Celiac Disease
Crohn's Disease
Digestive Conditions
Diverticulitis
Eating Disorder
Esophageal Disorder
Hiatal Hernia
Intestinal Polyps
Irritable Bowel Syndrome
Stomach Disorder
Ulcerative Colitis
Other Gastrointestinal
Comments
Abdominal Hernia
Acid Reflux
Celiac Disease
Crohn's Disease
Digestive Conditions
Diverticulitis
Eating Disorder
Esophageal Disorder
Hiatal Hernia
Intestinal Polyps
Irritable Bowel Syndrome
Stomach Disorder
Ulcerative Colitis
Other Gastrointestinal
Hearing
Conductive Hearing Loss
Ear Problems
Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Other Hearing
Comments
Conductive Hearing Loss
Ear Problems
Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Other Hearing
Kidney
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Other Kidney
Comments
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Other Kidney
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
Temporomandibular 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
Temporomandibular Joint Dysfunction
Tendonitis/Bursitis
Torticollis
Whiplash
Other Musculoskeletal
Neurological
Bell's Palsy
Brain Disorder
Brain Injury
Carpal Tunnel
Cerebral Palsy
Cerebral Vascular Accident (Stroke)
Epilepsy
Fatigue
Fibromyalgia
Herniated Disc
Huntington Disease
Loss of Sensation
Multiple Sclerosis
Parkinsons
Peripheral Neuropathy
Post Polio Syndrome
Sciatic Pain
Seizure Disorder
Sleeping Disorders
Transient Ischemic Attacks (TIA)
Vertebral and Spinal Cord Injury
Other Neurological
Comments
Bell's Palsy
Brain Disorder
Brain Injury
Carpal Tunnel
Cerebral Palsy
Cerebral Vascular Accident (Stroke)
Epilepsy
Fatigue
Fibromyalgia
Herniated Disc
Huntington Disease
Loss of Sensation
Multiple Sclerosis
Parkinsons
Peripheral Neuropathy
Post Polio Syndrome
Sciatic Pain
Seizure Disorder
Sleeping Disorders
Transient Ischemic Attacks (TIA)
Vertebral and Spinal Cord Injury
Other Neurological
Respiratory
Asthma
Bronchitis
Chronic Cough
COPD
Cystic Fibrosis
Emphysema
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
Shortness of Breath
Sinus Problem
Tuberculosis
Other Respiratory
Comments
Asthma
Bronchitis
Chronic Cough
COPD
Cystic Fibrosis
Emphysema
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
Shortness of Breath
Sinus Problem
Tuberculosis
Other Respiratory
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