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Client Intake- Brittany Stanley LMBT 7133
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Left Hip
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Right Hip
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Right Groin
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Right Knee
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Right Foot
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Brain Injury
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Transient Ischemic Attacks (TIA)
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Loss of Sensation
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Shingles / Herpes
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Burning
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Multiple Sclerosis
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Sleeping Disorders
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Myasthenia Gravis
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Carpal Tunnel Syndrome
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Ankylosing Spondylitis
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Athletes Foot
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Using Accutane
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Infectious Skin Conditions
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Rash
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Using Latisse
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Cosmetic Surgery
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Melanoma
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Rosacea
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UV Burn
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Dermatographia
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Melanoma/Carcinoma
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Severe Irritability
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Acne
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Eczema
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Moles
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Skin Conditions
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Allergic Dermatosis
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Allergic to Iodine
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Combination Skin
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Dry Skin
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Oily Skin
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Mature Skin
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Sensitive Skin
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Sun Damage
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Using ALPHA Hydroxy Acids
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Using RETIN A
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Respiratory
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Asthma
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Respiratory Tract Infection
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Bronchitis
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Shortness of Breath
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Chronic Cough
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Sinus Problem
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COPD
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Tuberculosis
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Cystic Fibrosis
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Emphysema
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Infectious Respiratory Conditions
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Prenatal (check boxes to enter details below)
Any pregnancy complications or health issues?
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Weeks Pregnant
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Number of previous pregnancies/births?
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Anemia
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Leaking Amniotic Fluid
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Bladder Infection
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Blood Clot (Phlebitis)
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Miscarriage
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Nausea
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Problems with Placenta
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Preterm Labour
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Pre-eclampsia (toxemia)
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Sciatica
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Separation of Rectus Muscle (diastasis recti)
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Separation of Symphysis Pubis
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Twins or More
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Visual Disturbances
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Previous C-Section
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Heart Attack
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Stroke
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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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Birth Location
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Doula
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Placental Location
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Baby's Sex
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Sacral Injury
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Tailbone Injury
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Massage Goals
Flexibility
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Improve Fitness
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Increase Well-Being
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Injury Rehabilitation
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Pain Relief
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Positive Reinforcement
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Stress Relief
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Address Health Issues
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Date of Last Massage
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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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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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Steroids (oral) 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 therapies
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Allergy
Environmental
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Food
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Latex
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Mastocytosis
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MCAD
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Medical
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Miscellaneous
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Coconut Oil
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Sensitive to scents/essential oils
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