Forms

  • Emergency Contact Information :
  • Emergency Contact Telephone:
  •  Health History- Be detailed.
  • What is your occupation?
  • How did you hear about us? (Instagram, Facebook, Google, Sign, Advertising, Radio, Magazine, Friend- please name)
  • Have you had a therapeutic massage or osteo before? If yes, for what condition?
  • Are you currently being treated by a Chiropractor or Physical Therapist or Massage Therapist or Acupuncturist?
  • Have you had any injuries in the past 72 hours?
  • If yes, please explain with as much detail:
  • Please list ALL past surgeries (INCLUDE DATES):
  • Please list ALL injuries/motor vehicle accidents/trauma(INCLUDE DATES):Please list ALL CURRENT PERSCRIBED MEDICATIONSPlease list ALL CURRENT SUPPLEMENTSPlease list any other MEDS/DRUGSAllergies:
  •  Digestive: Please use “C” for current issues or “P” for previous conditions
    • Constipation:
    • Nausea/vomiting:
    • Ulcers/blood in stool:
    • Liver/kidney problems:
    • Quick weight loss:
    • Quick Weight gain:
    • Appetite Changes:
    • Ulcerated colitis:
    • Chrohn’s disease:
    • Irritable Bowel Syndrome:
    • Other:
  •  Respiratory Conditions: Please use “C” for current issues or “P” for previous conditions
    • Chronic cough:
    • COPD:
    • Shortness of breath:
    • Bronchitis/Asthmas:
    • Sinus infections:
    • Emphysema:
    • Smoke/Vape:
    • COVID 19:
    • Other:
  •  Cardiovascular: Please use “C” for CURRENT issues or “P” for PAST/PREVIOUS conditions (indicate year if applicable)
    • Cold hands:
    • Cold feet:
    • Swelling in hands:
    • Swelling in feet:
    • Lymphedema:
    • Blood clots:
    • High blood pressure:
    • Low blood pressure:
    • Myocardial infarction:
    • Heart disease:
    • Congestive Heart Failure or Heart attack:
    • Cardiovascular accident:
    • Cerebralvascular accident:
    • Varicose veins:
    • Phlebitis:
    • Poor healing of wounds:
    • Stroke/CVA:
    • Thrombosis/embolism:
    • Pacemaker or other devices:
    • Other:
  •  Skin: Please use “C” for current issues or “P” for previous conditions
    • Bruise easily:
    • Rash:
    • Open sores:
    • Contagious skin disease:
    • Psoriasis:
    • Eczema:
    • Other:
  •  Head and Neck: Please use “C” for current issues or “P” for previous conditions
    • Tension/migraine headaches:
    • Tinnitus (ringing in ears)
    • Tooth pain
    • Jaw pain
    • Ear pain
    • Vision problems/loss
    • Hearing loss
    • Dizziness/lightheaded
    • Whiplash
    • Head trauma
    • Concussion
    • Neck pain
    • Neck stiffness
    • Neck injury
    • Other:
  •  Other Conditions
    • Depression
    • Loss of sensation
    • Diabetes(Type 1 or 2)
    • Epilepsy
    • Insomnia
    • Multiple Sclerosis
    • Parksinsons
    • Cancer (onset/type)
    • Other
  •  Click Soft Tissue Dysfunctions; Please use “C” for current issues or “P” for previous conditions
    • Fibromyalgia
    • Rhematoid arthritis
    • Osteoarthritis
    • Osteoporosis
    • Broken bones
    • Fractures
    • Throcic outlet syndrome
    • Tendonitis/Tenosynovitis
    • Bursitis
    • Dislocations
    • Carpel tunnel syndrome
    • Plantar Fasciitis
  •  Infections
    • Current infection:
    • Hepatitis:
    • Tuberculosis:
    • HIV:
    • Myocarditis:
  •  Women Specific: Please select what applies and also add details
  • Are you pregnant? (Due date?) Y/N
  • Are you currently trying to get pregnant? Y/N
  • IF YES, How long have you been trying if Yes?
  • Total Pregnancies:
  • Total Miscarriages:
  • Total Abortions:
  • Total C-sections:
  • Do you use any form of contraceptives? Y/N
  • If yes, what method of contraceptive do you use?
  •  Women’s Health Concerns
  • Endometriosis Uterine FibriodsPain during sexGynological concernsChronic UTIHysterectomyIrregular PeriodsInfertilityHeavy bleeding or Painful PeriodsMenapausal related dysfunctionsPMSAbdominal PainPelvic PainOther
  •  Overall wellness scale from 0-10 (0=POOR and 10=OPTIMAL)
    • Sleep
    • Diet
    • Digestion
    • Exercise
    • Overall wellness
  •  WHAT ARE YOU EXPERIENCING IN THE BODY? Head to toe, list all of the concerns you currently have, and for each concern, note that the additional 4 questions will be asked: CONCERN, ONSET, LOCATION, DURATION, INTENSITY, FREQUENCY, ADL, AGGRAVATING AND RELIEVING FACTORS
  • CHARACTERISTICS ( PAIN, TINGLING, PINS/NEEDLES, BURNING, WEAKNESS, SPASM, IRRITATED, SHARP, DULL, ACHE)
  • WHEN DID THIS START?
  • HOW FREQUENT AND WHEN DOES THIS HAPPEN?
  • INTENSITY- PAIN SCALE 0-10
  •  Primary Concern
    • Please describe your PRIMARY CONCERN-How long have you had this issue:
    • How did it start?
    • Describe your pain level from 0-10 0: No pain or 10: Serious Pain
    • What aggravates it?
    • What relieves it?
    • List CURRENT activities, hobbies, sports
    and the effect this concern has on your daily life:

  •  YOUR CHILDS BIRTH STORY: Please be as detailed as possible. Any physical, emotional, or environmental traumas in Utero (and what week), length of labour, complications, ) LIST EVERYTHING!!
  •  YOUR PERSONAL BIRTH STORY- length of labor, vaginal or cesarian, complications, family stress factors, trauma
  •  SELECT GOALS THAT RESONATE BEST WITH YOU AT THIS TIME Goal examples- lifestyle, comfort, activities, or abilities, improve range of motion, reduce discomfort, headaches, migraines, engage the parasympathetic nervous system, stress, fertility, relaxation, spinal and pelvic alignment, pelvic floor strengthening, pelvic floor muscle relaxation, muscle tension, muscle strengthening, cranial bone alignment, lymphatic drainage, posture, edema, wellness, balance,
  • LIST 2 SHORT TERM GOALS
  • LIST 2 LONG TERM GOALS
  • prenatal/postnatal care,
  •  Additional notes