Daily Intake v2.1b (Medical Massage)

I have new accidents/injuries since my last visit (Please remind your therapist before the session); Add to injury list in the next section.

I have no new injuries to note

I have a new pain of unknown cause; add to the injury list in the next section. (Note unknown cause in comment)

ONLY ADD NEW INJURIES SINCE YOU'RE LAST VISIT
If this is your first visit, you should have added them to your client intake. If not, add them here.

Medication List
Only add medications you've started or stopped taking since your last visit.

AS NEEDED MEDS (Below):
Spelling does not need to be exact.

If you have not changed the medication we have on file, the list could even be "Muscle relaxer" if you're only taking one.

"As needed" Medication use in the last week seemed

I had an aggravating factor that caused a change in the use of medications.

As needed medications of note: **i.e. anything due to or affecting the conditions we're treating**; dose & frequency; BOTH: Prescription & Over the counter; Nerve, pain meds (oral or topical), muscle relaxers, sleep aids, other

Massage Therapy Goals

Add Aroma therapy please; Note which ones: Lavender, Peppermint, Eucalyptus, Woodsie (Blend), Clean/Refreshing (Blend) are typical ones kept on hand

I need a feather light touch

I need lighter pressure (Describe)

I need deeper pressure (Describe)

Last Primary Care Visit

Last Chiropractic Visit

Date of last physical therapy visit

Date of last massage if done elsewhere

If you've had any recent injections, laser treatments, or similar, please add them to the surgery/procedure section below:

I have minor aggravating factors. What makes your complaints worse {I.e. work, walking a lot, sitting a lot, etc}

What helps your complaints

Yoga

Thai Chi

Weights

None (Time)

None : Too much pain (Skipped one or more due to pain)

Cardio

Other

Meditation

Breathing exercises

Acupuncture

These additional treatments haven't helped, and thus, I stopped (Date/Timeframe)

How many hours have you been sleeping per night in the last 72 hours (Is that better/worse/typical?)

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Stress/Pain is affecting the ability to work

Stress/Pain is affecting my daily routine

I have been unable to work since

There was an aggravating factor to counteract the positive effects of massage therapy (Describe)

Tension

Migraine

Cluster headaches

Aura

Temperature Based

Weather related

Illness Causation

Allergies

Describe

Other A (0-10):

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Other B (0-10):

Characters: 0/255

Other C (0-10):

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Hand Weakness

Carpal Tunnel Pain (wrist/forearm)

Numbness or tingling in the arm

Numbness or tingling in the hand

Hand Weakness

Carpal Tunnel Pain (wrist/forearm)

Numbness or tingling in the arm

Numbness or tingling in the hand

I have low back pain

I have numbness or tingling in the glutes

I have pain in the glutes

I have pain in my hamstrings

I have numbness or tingling in my hamstrings

I have pain in my calves

I have numbness or tingling in my calves

I have pain in my low back

I have numbness or tingling in the glutes (Bum)

I have pain in the glutes (Bum)

I have pain in my hamstrings

I have numbness or tingling in my hamstrings

I have pain in my calves

I have numbness or tingling in my calves

Describe your issues

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I can touch my toes

Flat hands on the floor with straight legs

Tips of fingers with straight legs

Only touch my shins with a straight leg

Only touch my knees with straight legs

I can touch my toes only if I bend my knees

I can only touch my toes if sitting

I can not touch my toes

I can put my left hand

I can put my right hand

Wrist to my spine (low back)

Knuckles to my spine (low back)

Fingertips to my spine (low back)

Barely to the edge of my low back

I can not put my hand behind my low back

I can lift my left arm

nowhere

to my shoulder

A little above my shoulder with help to (40-45+ degrees)

A little above my shoulder on my own (40-45+ degrees)

straight up along my head with help

straight up along my head without help

I can lift my right arm

nowhere

to my shoulder

A little above my shoulder with help to (40-45+ degrees)

A little above my shoulder on my own (40-45+ degrees)

straight up along my head with help

straight up along my head without help