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Improve Lifestyle
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Area of Complaint
Neck
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Upper Back
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Mid Back
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Low Back
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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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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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Left Calf
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Right Leg
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Right Calf
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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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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Sacrum
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Headaches
Migraines
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Headaches
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Cluster
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Sinus
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Chronic Daily Headache
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Tension
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Other Headaches
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Family History
Cancer
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Diabetes
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Arthritis
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Cardiovascular
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Respiratory
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Musculoskeletal
Joint Stiffness / Swelling
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Jaw Pain (TMJD)
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Osgood-Schlatter Disease
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Plantar Fasciitis
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Tendonitis/Bursitis
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Scoliosis
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Whiplash
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Osteoarthritis
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Arthritis
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Strain/Sprain
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Spondylolisthesis
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Osteoporosis
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Temporomandibular Joint Dysfunction
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Artificial Joints / Special Equipment
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Ankylosing Spondylitis
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Degenerative Disk Disease
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Compartment Syndrome
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Sinus Problems
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Ehlers-Danlos Syndrome
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Dislocation
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Fibromyalgia
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Other Musculoskeletal
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Neurological
Sciatic Pain
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Fatigue
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Fibromyalgia
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Carpal Tunnel
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Cardiovascular
Pacemaker
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Blood Clots
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Hearing
Vertigo
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Massage Goals
Injury Rehabilitation
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Pain Relief
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Address Health Issues
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Positive Reinforcement
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Balance
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Strength Training
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Flexibility
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Stress Relief
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Improve Fitness
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Improve Symptoms
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Increase Well-Being
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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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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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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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Heat Did it help?
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Cold Did it help?
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