Emelia James, RMT
Massage Therapy Clinical Intake: Health History
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Australia (+61)
Canada (+1)
Ireland (+353)
New Zealand (+64)
United Kingdom (+44)
United States (+1)
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Virgin Islands, U.S.
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Emergency Contact
Emergency Contact
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Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Medical Info
Primary Complaint
General Health
Source of Referral
Current Treatment
Past Treatment (from other practitioners)
Medications
Injuries
Surgeries
Additional Info
Conditions
Treatment Goals
Health Advice for Healing
Improve Well Being
Pain Relief
Rehabilitation
Stress Relief
Improve Symptoms
Comments
Health Advice for Healing
Improve Well Being
Pain Relief
Rehabilitation
Stress Relief
Improve Symptoms
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
Headaches
Migraines
Comments
Headaches
Migraines
Family History
Arthritis
Cardiovascular
Respiratory
Comments
Arthritis
Cardiovascular
Respiratory
Blood
Bleeding Disorder
Blood Thinner Medication
Haemophilia
Hepatitis
Hypercoagulability
Thrombosis/Embolism
Comments
Bleeding Disorder
Blood Thinner Medication
Haemophilia
Hepatitis
Hypercoagulability
Thrombosis/Embolism
Cardiovascular
Aneurysm
Atherosclerosis
Blood Clots
Congestive Heart Failure
Heart Attack
Heart Disease
High Blood Pressure
Low Blood Pressure
Lymphedema
Pacemaker
Stroke
Varicose Veins
Heart Condition
Comments
Aneurysm
Atherosclerosis
Blood Clots
Congestive Heart Failure
Heart Attack
Heart Disease
High Blood Pressure
Low Blood Pressure
Lymphedema
Pacemaker
Stroke
Varicose Veins
Heart Condition
Endocrine
Diabetes
Hyperthyroidism
Hypothyroidism
Comments
Diabetes
Hyperthyroidism
Hypothyroidism
Gastrointestinal
Crohn's Disease
Digestive Conditions
Irritable Bowel Syndrome
Ulcerative Colitis
Acid Reflux
Comments
Crohn's Disease
Digestive Conditions
Irritable Bowel Syndrome
Ulcerative Colitis
Acid Reflux
Hearing
Ear Problems
Hearing Loss
Tinnitus
Vertigo
Comments
Ear Problems
Hearing Loss
Tinnitus
Vertigo
Immune
Allergies
Cancer
Rheumatoid Arthritis
HIV/Aids
Lupus
Comments
Allergies
Cancer
Rheumatoid Arthritis
HIV/Aids
Lupus
Musculoskeletal
Adhesive Capsulitis
Ankylosing Spondylitis
Arthritis
Artificial Joints / Special Equipment
Bone or Joint Disease
Carpal Tunnel Syndrome
Chronic Myofascial Pain Syndrome
Compartment Syndrome
Degenerative Disk Disease
Fibromyalgia
Jaw Pain (TMJD)
Osgood-Schlatter Disease
Osteoarthritis
Osteoporosis
Plantar Fasciitis
Scoliosis
Strain/Sprain
Tendonitis/Bursitis
Torticollis
Broken Bone / Fracture
Dislocation
Joint Stiffness / Swelling
Osteomalacia
Spasms / Cramps
Whiplash
Other Musculoskeletal
Comments
Adhesive Capsulitis
Ankylosing Spondylitis
Arthritis
Artificial Joints / Special Equipment
Bone or Joint Disease
Carpal Tunnel Syndrome
Chronic Myofascial Pain Syndrome
Compartment Syndrome
Degenerative Disk Disease
Fibromyalgia
Jaw Pain (TMJD)
Osgood-Schlatter Disease
Osteoarthritis
Osteoporosis
Plantar Fasciitis
Scoliosis
Strain/Sprain
Tendonitis/Bursitis
Torticollis
Broken Bone / Fracture
Dislocation
Joint Stiffness / Swelling
Osteomalacia
Spasms / Cramps
Whiplash
Other Musculoskeletal
Neurological
Bell's Palsy
Brain Injury
Cerebral Palsy
Dizziness
Epilepsy
Herniated Disc
Huntington Disease
Loss of Sensation
Multiple Sclerosis
Parkinsons
Sciatic Pain
Seizure Disorder
Stroke
Transient Ischemic Attacks (TIA)
Vertebral and Spinal Cord Injury
Chiari Malformation
Peripheral Neuropathy
Comments
Bell's Palsy
Brain Injury
Cerebral Palsy
Dizziness
Epilepsy
Herniated Disc
Huntington Disease
Loss of Sensation
Multiple Sclerosis
Parkinsons
Sciatic Pain
Seizure Disorder
Stroke
Transient Ischemic Attacks (TIA)
Vertebral and Spinal Cord Injury
Chiari Malformation
Peripheral Neuropathy
Reproductive
Gynaecological Conditions
Pregnancy
Comments
Gynaecological Conditions
Pregnancy
Respiratory
Asthma
Bronchitis
Chronic Cough
COPD
Cystic Fibrosis
Emphysema
Shortness of Breath
Tuberculosis
Infectious Respiratory Conditions
Comments
Asthma
Bronchitis
Chronic Cough
COPD
Cystic Fibrosis
Emphysema
Shortness of Breath
Tuberculosis
Infectious Respiratory Conditions
Skin
Bruise Easily
Herpes
Hypersensitive Reactions
Infectious Skin Conditions
Skin Conditions
Sensitive Skin
Comments
Bruise Easily
Herpes
Hypersensitive Reactions
Infectious Skin Conditions
Skin Conditions
Sensitive Skin
Miscellaneous
Loss of Balance
Mental Health Issues
Surgical Pins or Wire
Vision Loss
Vision Problems
Other Medical Conditions
Other Diagnosed Diseases
Comments
Loss of Balance
Mental Health Issues
Surgical Pins or Wire
Vision Loss
Vision Problems
Other Medical Conditions
Other Diagnosed Diseases
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