Even Keel Wellness Spa (51-0475299)
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Medical Info
Primary Complaint
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General Health
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Heart Condition
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Past Heart Surgery
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Asthma
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Concussion
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Congenital Heart Defect
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Hearing Impairment
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Heart Attack
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
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Willing to wash hands before 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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Fever Over 100.4 degrees
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Headaches
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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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Shortness of Breath
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Fatigue
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Chills
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Runny nose/nasal congestion without other known cause
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Sudden onset body aches
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New rash or other skin changes
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Are you considered high risk?
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Spend time around anyone that is high risk
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If over 70, worsening of chronic conditions?
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Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Mid Back
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Right Side of Mid Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Right Leg
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Headaches
Headaches
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Sinus
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Chronic Daily Headache
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Tension
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Migraines
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Respiratory
Cystic Fibrosis
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Tuberculosis
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Respiratory Conditions
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Chronic Cough
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Shortness of Breath
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Infectious Respiratory Conditions
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Asthma
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Emphysema
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Bronchitis
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Respiratory Tract Infection
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COPD
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Musculoskeletal
Carpal Tunnel Syndrome
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Sinus Problems
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Tendonitis/Bursitis
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Fibromyalgia
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Dislocation
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Fracture
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Joint Injury
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Osteoarthritis
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Arthritis
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Scoliosis
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Strain/Sprain
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Osteoporosis
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Gout
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Artificial Joints / Special Equipment
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Bone or Joint Disease
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Jaw Pain (TMJD)
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Skin
Athlete's Foot
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Chemical Burn
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Plantar's Wart
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Herpes
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Psoriasis
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Bruise Easily
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Rash
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Other Skin
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Blood
Hypercoagulability
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Thrombosis/Embolism
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High Cholesterol
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Hepatitis
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HIV
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Haemophilia
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Anemia
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Bleeding Disorder
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HIV/AIDS
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Cardiovascular
Blood Clots
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Aneurysm
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High Blood Pressure
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Low Blood Pressure
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Immune
Allergies
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Cancer
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Other Immune
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Prenatal (check boxes to enter details below)
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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Massage Goals
Injury Rehabilitation
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Strength Training
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Stress Relief
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Address Health Issues
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Alternative Therapy
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Balance
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Flexibility
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Improve Fitness
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Increase Well-Being
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Date of Last Massage
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Light Pressure Preferred
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Medium Pressure Preferred
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Deep Pressure Preferred
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Physical Activities You Participate In
Pilates
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Waterpolo
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Rugby
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Weight Lifting
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Baseball
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Running
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Yoga
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Crossfit
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Soccer
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Football
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Softball
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Golf
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Swimming
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Lacrosse
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Tennis
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Marathon
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Triathlon
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Other Activities
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