Mountain View Massage and Wellness
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Medical Info
Primary Complaint
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General Health
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Current Treatment
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Stress Relief
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Support in Healing/Recovery
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Improve Well Being
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Other
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TMJ (Jaw)
Clenching
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Clicking
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Grinding
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Jaw Pain
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Locking
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Well Being
Caffeine
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Drinking
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Exercise
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Smoking
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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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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
Sinus
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Chronic Daily Headache
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Tension
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Migraines
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Headaches
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Immune
Rheumatoid Arthritis
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Other Immune
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Neurological
Epilepsy
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Carpal Tunnel
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Sciatic Pain
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Numbness
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Stroke
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Tingling
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Parkinsons
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Brain Injury
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Herniated Disc
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Multiple Sclerosis
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Other Neurological
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Gastrointestinal
Poor Appetite
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Digestive Conditions
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Celiac Disease
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Constipation
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Crohn's Disease
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Diarrhea
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Eating Disorder
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Other Gastrointestinal
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Cardiovascular
Chest Pain
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Heart Attack
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Cold Hands
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Heart Condition
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Cold Feet
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Swelling
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Heart Disease
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Blood Pressure
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Other Cardiovascular
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Musculoskeletal
Dislocation
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Tendonitis/Bursitis
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Arthritis
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Fracture
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Scoliosis
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Gout
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Osteoporosis
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Strain/Sprain
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Fibromyalgia
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Plantar Fasciitis
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Joint Stiffness / Swelling
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Osteoarthritis
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Other Musculoskeletal
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Family History
Arthritis
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Cardiovascular
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Respiratory
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Prenatal (check boxes to enter details below)
Any pregnancy complications or health issues?
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Due Date
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Weeks Pregnant
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Allergy
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Food
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Sensitive to scents/essential oils
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