Client Intake- Brittany Stanley LMBT 7133
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Australia
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Senegal
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Spain
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Swaziland
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Emergency Contact
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
Meniere Disease
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Vertigo
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Asthma
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Epilepsy
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Migraines/Headaches
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Warts
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Blood thinner medication
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Gastrointestinal
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Mood Disorder
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Cancer
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Hearing Impairment
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Pacemaker
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Cardiovascular
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Heart Attack
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Past Heart Surgery
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Concussion
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Heart Condition
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Schizophrenia
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Congenital Heart Defect
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High blood pressure
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Stroke
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Depression
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HIV/Aids
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Low blood pressure
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Varicose veins
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Diabetes
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Well Being
Water Intake
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Exercise
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Flexibility
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Hobbies
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Range of Motion
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Smoking
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Sports
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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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Headaches
Migraines
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Rebound
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Sinus
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Tension
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Chronic Daily Headache
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Cluster
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Headaches
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Other Headaches
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Neurological
Stabbing
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Cerebral Palsy
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Epilepsy
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Parkinsons
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Stroke
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Cerebral Vascular Accident (Stroke)
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Fatigue
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Peripheral Neuropathy
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Syringomyelia
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Cerebral-vascular Accident
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Fibromyalgia
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Post Polio Syndrome
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Bell's Palsy
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Tethered Cord
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Cerebrospinal Fluid Leak
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Herniated Disc
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Sciatic Pain
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Brain Disorder
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Tingling
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Chiari Malformation
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Huntington Disease
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Seizure Disorder
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Brain Injury
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Transient Ischemic Attacks (TIA)
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Chronic Pain Disorder
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Loss of Sensation
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Shingles
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Shingles / Herpes
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Burning
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Twitching of Face
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Dizziness
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Multiple Sclerosis
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Sleeping Disorders
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Carpal Tunnel
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Vertebral and Spinal Cord Injury
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Dural Ectasia
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Numbness
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Other Neurological
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Musculoskeletal
Gout
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Osgood-Schlatter Disease
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Arthritis
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Scleroderma
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Chronic Myofascial Pain Syndrome
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Torticollis
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Hereditary/Congenital Deformity
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Osteoarthritis
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Artificial Joints / Special Equipment
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Scoliosis
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Compartment Syndrome
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Whiplash
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Jaw Pain (TMJD)
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Osteomalacia
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Baker's Cyst
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Sinus Problems
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Degenerative Disk Disease
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Dislocation
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Joint Injury
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Osteoporosis
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Bone Disease
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Spasms / Cramps
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Paget Disease
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Bone or Joint Disease
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Spondylolisthesis
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Ehlers-Danlos Syndrome
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Muscular Dystrophy
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Adhesive Capsulitis
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Plantar Fasciitis
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Broken Bone / Fracture
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Strain/Sprain
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Fibromyalgia
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Myasthenia Gravis
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Amyotrophic Lateral Sclerosis (ALS)
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Psoriatic Arthritis
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Carpal Tunnel Syndrome
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Temporomandibular Joint Dysfunction
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Fracture
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Ankylosing Spondylitis
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Recti Diastasis
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Chronic Fatigue Syndrome
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Tendonitis/Bursitis
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Other Musculoskeletal
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Skin
Hair Transplant
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Non-Surgical Scars
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Skin Irritations
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Alopecia
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Herpes
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Pigmentary Disorder
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Surgical Scars
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Athlete's Foot
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Athletes Foot
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Hypersensitive Reaction
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Plantar's Wart
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Urticaria
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Bruise Easily
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Hypersensitive Reactions
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Psoriasis
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Using Accutane
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Chemical Burn
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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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Other Skin
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Respiratory
Respiratory Conditions
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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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Other Respiratory
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Prenatal (check boxes to enter details below)
Any pregnancy complications or health issues?
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Name of midwife/OBGYN
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Other prenatal concerns
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Due Date
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Trimester
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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 creams, gels or unguents
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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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Other Allergies
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