V4 Massage Health Intake
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Medical Info
Primary Reason/Complaint/Goal for your Appointment
General Health
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Current or Past Treatments from other Practitioners (with dates if possible)
Medications
Injuries
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Conditions
Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Heat Did it help?
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Cold Did it help?
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Other therapies
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General Injury Related Questions
Treatment of previous injury?
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Physical Therapy
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Chiropractic
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Surgery (type/year)
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Complications from that injury?
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Well Being
Caffeine
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Interests
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Exercise / Strength Training
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Smoking
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Sports
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Flexibility / Yoga
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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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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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Tailbone (coccyx)
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Musculoskeletal
Dislocation
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Arthritis
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Joint Injury
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Broken Bone / Fracture
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Osteoporosis
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Scoliosis
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Tendonitis/Bursitis
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Carpal Tunnel Syndrome
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Joint Stiffness / Swelling
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Strain/Sprain
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Artificial Joints / Special Equipment
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Osteoarthritis
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Degenerative Disk Disease
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Plantar Fasciitis
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Other Musculoskeletal
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Energy
How long do you sleep on average?
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Emotion / Memory
Stress
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Anxiety Disorder
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TMJ (Jaw)
Jaw Pain
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Clicking
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Locking
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Difficulty Chewing
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Morning Stiffness
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Brain Disorders
Sleep Disorder
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ADHD
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Headaches
Migraines
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Headaches
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Skin
Skin Conditions
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Bruise Easily
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Athletes Foot
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Eczema
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Plantar's Wart
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Infectious Skin Conditions
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Cardiovascular
Heart Attack
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Blood Pressure
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Lymphedema
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Pacemaker
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Blood Clots
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Aneurysm
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Stroke
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Varicose Veins
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Cold Hands
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Cold Feet
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Other Cardiovascular
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Neurological
Numbness
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Burning
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Shingles
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Sciatic Pain
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Tingling
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Stabbing
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Loss of Sensation
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Other Neurological
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Immune
Allergies
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Rheumatoid Arthritis
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Other Immune
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Oncology
Cancer Type
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Lymph Nodes Removed
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Treatment: Chemotherapy
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Treatment: Radiation
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Medical Devices
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Pressure Sensitivity
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Fragile Skin
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Gastrointestinal
Constipation
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Stomach Disorder
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Other Gastrointestinal
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Hearing
Vertigo
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Blood
Thrombosis/Embolism
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HIV/AIDS
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Hepatitis
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Other Blood
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Endocrine
Diabetes
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Miscellaneous
Surgical Pins or Wire
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Other Medical Conditions
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Other Diagnosed Diseases
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Emotion / Mood
Overall mood and energy level
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Rate the stress in your life (1-10)
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