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Bronchitis
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Substance Use Disorder
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Well Being
Caffeine
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Salt Intake
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Sports
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Flexibility
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Water Intake
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Interests
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Mobility/Walking Aids
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Range of Motion
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Have you ever seen a Naturopathic Doctor before?
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Are you currently taking any supplements/Natraceuticals?
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How often have you taken antibiotics in the last 2 years?
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Acupuncture
Sciatica
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Arthritis
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Carpal Tunnel
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Female Health
Hysterectomy
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Heavy Bleeding
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Endometriosis
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Infertility
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Unwanted hair growth
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Premenstrual Syndrome
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Breast Cancer
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Ovarian Cancer
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Osteoporosis
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Currently Pregnant
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Birth Control Method
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Implants
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Fibroids
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PCOS
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Uterine Polyps
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Spotting
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Dark Blood
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Clots
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Pencil Like Stool
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Urinary Incontinence
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Scar Tissue
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Energy
Do you struggle with insomnia?
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Does your energy fluctuate?
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How long do you sleep on average?
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Is your energy constant?
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What is your energy level upon awakening?
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When is your energy highest?
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When is your energy lowest?
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Genetics
Down Syndrome
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Ehlers-Danlos Syndromes
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Loeys-Dietz Syndrome
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Marfan Syndrome
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Mitochondrial Disease
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Other
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Infectious
Epstein Barr
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Lyme Disease
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Pneumonia
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Strep
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Changes to your medical history since initial intake?
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Willing to wash hands before entering clinic
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Willing to wash hands before leaving clinic
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Willing to sanitise hands when entering and leaving clinic
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Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you tested positive for COVID-19?
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Have you been tested for COVID?
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Have you had the antibody test?
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Have you been vaccinated?
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Fever Over 100.4 degrees
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Fever Over 38 degrees
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Headaches
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What is your Temperature?
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New Onset of Cough
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Worsening Chronic Cough
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Sore Throat
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Difficulty Swallowing
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Shortness of Breath
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Difficulty Breathing
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Decrease or sudden loss of taste and smell
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Have you had a new onset of muscle aches and pain since the emergence of the virus?
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Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
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Fatigue
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Chills
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If a child, purple markings on fingers and toes
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Pink eye (conjunctivitis)
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Nasal or sinus congestion
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Runny nose/nasal congestion without other known cause
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Nausea
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Vomiting
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Diarrhea
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Abdominal Pain
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Sudden onset body aches
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New rash or other skin changes
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Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
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Regular cardio exercise
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Can you exercise to get your heart rate up without any problem?
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Can you exercise to get your respiratory rate up without any problem?
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Contact with someone with COVID
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Had close contact with a confirmed case of COVID-19 without wearing PPE
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Are you in high or moderate risk groups?
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Have you been shielding?
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Contact with someone who is awaiting COVID test results.
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ADHD
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Vision Loss
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Liver Disease
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Autism
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Loss of Balance
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Contact Lens
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Mental Health Issues
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Music Preference
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Dental Bridge
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Surgical Pins or Wire
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Upper Respiratory Infection
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Dental Implants
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Visually Impaired
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Insomnia
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Dentures
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Weakened Immune Function
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Other Medical Conditions
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Other Diagnosed Diseases
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Eating Habits
Breakfast
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Lunch
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Dinner
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Snacks
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Prenatal (check boxes to enter details below)
Any pregnancy complications or health issues?
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Name of midwife/OBGYN
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Other prenatal concerns
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Due Date
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Trimester
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Weeks Pregnant
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Number of previous pregnancies/births?
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Anemia
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Leaking Amniotic Fluid
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Bladder Infection
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Blood Clot (Phlebitis)
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Miscarriage
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Nausea
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Problems with Placenta
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Preterm Labour
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Pre-eclampsia (toxemia)
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Sciatica
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Separation of Rectus Muscle (diastasis recti)
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Separation of Symphysis Pubis
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Twins or More
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Visual Disturbances
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Previous C-Section
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Heart Attack
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Stroke
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Carpal Tunnel Syndrome
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Allergy to Nut Oils
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Hypoglycemia
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High Risk Pregnancy
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Birth Location
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Doula
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Placental Location
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Baby's Sex
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Sacral Injury
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Tailbone Injury
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Postpartum (check boxes to enter details below)
Name of midwife/OBGYN
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Any birth/postpartum complications or health issues?
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Number of weeks postpartum
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Any current limitations on your activity?
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Other postpartum concerns
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Birth Location
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Vaginal or cesarean birth?
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Currently lactating or nursing?
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Date you gave birth
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Diastasis recti
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Have you seen your midwife/OBGYN since giving birth?
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Massage Goals
Improve Fitness
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Improve Symptoms
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Increase Well-Being
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Injury Rehabilitation
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Address Health Issues
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Pain Relief
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Alternative Therapy
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Positive Reinforcement
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Balance
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Strength Training
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Stress Relief
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Flexibility
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Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Medium Pressure Preferred
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Other
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Deep Pressure Preferred
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Workers Comp Claim
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Crime Victim Comp.
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Which best describes what you are experiencing
Pain
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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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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Physical Activities You Participate In
Weight Lifting
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Basketball
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Rugby
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Yoga
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Crossfit
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Running
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Football
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Soccer
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Golf
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Softball
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Hockey
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Swimming
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Lacrosse
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Tennis
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Baseball
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Marathon
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Triathlon
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Waterpolo
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Pilates
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Other Activities
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Number of Times of Week You Practice
Once a week
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2-4 times a week
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More than 4 times a week
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Less than a couple of times a month
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Allergy
Environmental
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Food
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Latex
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Mastocytosis
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MCAD
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Medical
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Miscellaneous
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Coconut Oil
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Sensitive to scents/essential oils
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Other Allergies
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Emotion / Mood
Stress Response and Coping Strategies
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Mental Abuse History
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Anger
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Negative Self-Talk
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Anxiety
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Other Emotions
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Overall mood and energy level
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Confusion
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Physical Abuse History
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Depression
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PTSD
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Despair
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Rate the stress in your life (1-10)
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Fear
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Sadness
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Grief
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