Desert Healing Massage
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Personal Info
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Emergency Contact
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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
Health Questions
Vertigo
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Gastrointestinal
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Hearing Impairment
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Asthma
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Heart Condition
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Blood thinner medication
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High blood pressure
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HIV/Aids
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Cancer
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Low blood pressure
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Cardiovascular
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Migraines/Headaches
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Congenital Heart Defect
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Stroke
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Diabetes
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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 Lifestyle
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Improve Symptoms
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Improve Well Being
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Other
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Feet
Plantar Fasciitis
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Pes Cavus (High Arch)
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Pes Planus (Flat Feet)
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Well Being
Range of Motion
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Sports
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Exercise
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Flexibility
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Hobbies
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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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Female Health
Currently Pregnant
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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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Tailbone (coccyx)
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Family History
Cardiovascular
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Diabetes
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Respiratory
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Arthritis
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Cancer
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Accident Info
Date of Injury
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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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Trimester
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Weeks Pregnant
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Diabetes
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Edema/Swelling
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Leg Cramps
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Sciatica
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High Risk Pregnancy
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Massage Goals
Pain Relief
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Stress Relief
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Alternative Therapy
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Balance
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Flexibility
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Improve Fitness
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Injury Rehabilitation
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Date of Last Massage
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Massage Frequency
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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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Ache
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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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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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Immobilization Did it help?
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Other therapies
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Number of Times of Week You Workout
Once a week
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2-4 times a week
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More than 4 times a week
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Less than a couple of times a month
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Allergy
Mastocytosis
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MCAD
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Medical
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Miscellaneous
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Sensitive to scents/essential oils
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Coconut Oil
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Environmental
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Food
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Latex
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Other Allergies
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