Mandatory Health History Form 2023
Required Field
Personal Info
First Name
Last Name
Pronouns
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
Treatment Goals
Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Improve Symptoms
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Improve Well Being
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Other
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Health Questions
Asthma
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Pacemaker
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Concussion
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Congenital Heart Defect
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Schizophrenia
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Depression
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Stroke
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Epilepsy
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Vertigo
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Hearing Impairment
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Heart Attack
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Heart Condition
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High/Low Blood Pressure
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Diabetes (Type I/Type II). Managed?
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low 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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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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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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Current Complaint
Pain Scale: 1-10
1
2
3
4
5
6
7
8
9
10
Least Amount of Pain Imaginable
Most Amount of Pain Imaginable
Date of Injury?
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Prescription pain meds 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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Which best describes what you are experiencing
Getting Worse
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Staying the Same
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Getting Better
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No Change
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Disabling
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Tension
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Ache
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Sharp/Shooting
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Imbalance
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Discomfort
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Constant
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Intermittent
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Increases with Activity
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Decreases with Activity
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Other
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Massage Goals
Stress Relief
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Address Health Issues
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Improve Symptoms
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Increase Well-Being
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Pain Relief
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Injury Rehabilitation
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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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General Injury Related Questions
Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Headaches
Headaches
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Migraines
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Sinus
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Tension
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Chronic Daily Headache
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Other Headaches
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Prenatal (check boxes to enter details below)
Due Date
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Weeks Pregnant
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Number of previous pregnancies?
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Number of Previous Births?
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Anemia
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Blood Clot (Phlebitis)
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Gestational Diabetes
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Edema/Swelling
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Leg Cramps
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Nausea
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Pre-eclampsia (toxemia)
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Sciatica
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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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Sacral Injury
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Tailbone Injury
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Allergy
Environmental
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Food
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Latex
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Medical
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Other Allergies
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TMJ (Jaw)
Grinding
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Jaw Pain
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Locking
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Clenching
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Clicking
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Difficulty Chewing
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Difficulty Opening Jaw
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Feet
Onychomycosis (Nail Fungus)
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Pes Cavus (High Arch)
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Pes Planus (Flat Feet)
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Plantar Fasciitis
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Plantar Wart
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Bunions
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Dry/Cracked Skin
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Heel Fissures
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Treatment: Chemotherapy
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Treatment: Radiation
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Area of Radiation
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Medical Devices
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Lymphedema
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Hair Loss
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Radioactivity
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Immune
Anaphylaxis
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Non-Hodgkin Lymphoma
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Cancer
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Rheumatoid Arthritis
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CVID
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HIV/Aids
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Hodgkin Lymphoma
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Infectious Mononucleosis
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Leukemia
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Allergies
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Lupus
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Other Immune
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Cardiovascular
Atherosclerosis
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Coronary Artery Disease
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Pericarditis
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Varicose Veins
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Blood Clots
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Heart Attack
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Peripheral Vascular Disease
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Heart Condition
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Phlebitis
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Cardiac Arrhythmia
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Heart Disease
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Raynaud Disease
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Cardiovascular Conditions
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High Blood Pressure
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Rheumatic Heart Disease
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Chest Pain
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Low Blood Pressure
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Stroke
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Acute Coronary Syndrome
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Aneurysm
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Congenital Heart Defect
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Lymphedema
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Swelling
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Angina
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Congestive Heart Failure
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Pacemaker
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Valve Disorders
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Other Cardiovascular
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Musculoskeletal
Plantar Fasciitis
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Joint Injury
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Torticollis
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Baker's Cyst
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Degenerative Disk Disease
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Psoriatic Arthritis
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Joint Stiffness / Swelling
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Whiplash
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Bone Disease
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Dislocation
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Dupuytren's Contracture
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Scoliosis
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Muscular Dystrophy
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Bone or Joint Disease
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Fibromyalgia
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Sinus Problems
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Osgood-Schlatter Disease
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Adhesive Capsulitis
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Broken Bone / Fracture
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Spasms / Cramps
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Osteoarthritis
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Amyotrophic Lateral Sclerosis (ALS)
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Carpal Tunnel Syndrome
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Gout
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Spondylolisthesis
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Osteomalacia
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Ankylosing Spondylitis
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Chronic Fatigue Syndrome
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Hereditary/Congenital Deformity
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Strain/Sprain
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Osteoporosis
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Arthritis
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Chronic Myofascial Pain Syndrome
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Jaw Pain (TMJD)
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Tendonitis/Bursitis
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Artificial Joints / Special Equipment
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Compartment Syndrome
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Other Musculoskeletal
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Neurological
Shingles
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Cerebral Palsy
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Huntington Disease
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Loss of Sensation
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Cerebral-vascular Accident
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Multiple Sclerosis
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Stroke
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Cerebrospinal Fluid Leak
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Numbness/Tingling/Stabbing/Burning/Altered Sensation
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Bell's Palsy
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Dizziness
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Parkinsons
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Vertebral and Spinal Cord Injury
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Brain Disorder
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Epilepsy
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Peripheral Neuropathy
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Brain Injury
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Fatigue
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Sciatic Pain
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Fibromyalgia
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Seizure Disorder
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Carpal Tunnel
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Herniated Disc
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Other Neurological
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Gastrointestinal
Irritable Bowel Syndrome
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Ulcerative Colitis
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Abdominal Hernia
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Crohn's Disease
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Diverticulitis
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Other Gastrointestinal
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Skin
Bruise Easily
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Psoriasis
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Cosmetic Surgery
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Rash
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Eczema
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Rosacea
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Herpes
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Skin Conditions
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Hypersensitive Reaction
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Skin Irritations
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Surgical Scars
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Infectious Skin Conditions
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Alopecia
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Melanoma/Carcinoma
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Athlete's Foot
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Pigmentary Disorder
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Other Skin
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Endocrine
Blood Sugar Managed?
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Diabetes
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Hyperthyroidism
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Hypothyroidism
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Wound Healing Status?
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Other Endocrine
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Hearing
Ear Problems
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Hearing Loss
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Tinnitus
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Vertigo
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Other Hearing
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Family History
Arthritis
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Cancer
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Cardiovascular
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Diabetes
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Respiratory
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