Full Name*

Birth Date*

Address*





Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe

Phone Number*

This is my:*
HomeMobileWork

Email*

Emergency Contact*

Phone Number*

Occupation

Medications

Allergies

History of Pathology

1. List Areas of Discomfort or Pain*

2. Describe Onset of Discomfort or Pain*

3. Rate of Pain Today*
1 - Very Little23345678910 - Very Strong

4. Frequency - please select the most accurate*
ConstantOff/OnAt RestWith Activity

5. At what time of day is the pain at its worse?*
MorningAfternoonEveningDuring Sleep

6. Have you ever injured this area before?*

7. Have you ever been in an accident (automobile, work, falls, etc.) ?*

8. List all related treatments received for this injury.

9. Have you ever received a therapeutic massage for a specific problem or injury?

Was the treatment used effective?

10. Is there anything that you do that creates, increases or decreases pain?*

11. What are the physical duties required of your occupation?

12. What activities/hobbies do you enjoy?

13. Please list exercise and stress reduction activities (including frequency).

14. In what position do you most often wake up?*
BackSideStomach

15. Are you currently seeing any other healthcare professional

Please check any symptoms that apply to you and indicate right or left when applicable:

Head
TemplesForeheadTop of headIn the EyesEntire HeadBase of SkullDizzinessFaintingLight-HeadednessPain in EarsRinging in the Ears

Neck
StiffnessPain at Neck Shoulder JunctionPain when Turning HeadPain with Side to Side MovementsNeck feels out of placeMuscle Spasm in neckGliding/Granting sound with neck movementDiagnosed bone spursDiagnosed disc harniation

Shoulders
Pain in ShoulderFrontBackSidePain deep in shoulder jointDiagnosed BursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over head

Arms & Hands
Pain in upper armPain in forearmPain in wristPain inm fingersSensation of pins and needles in armsSensation of pins and needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strength

Mid-back
Mid-back painPain between shoulder bladesPain up/down backPain across mid-backPain with breathing

Low-back
Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in lowLow back feels out of

Hip
Pain in buttocksPain in buttocks when standingPain in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritis

Legs and Feet
Pain down RIGHT LegPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT FootNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT ankleSwollen RIGHT footSwollen LEFT footPain in RIGHT footPain in LEFT footPain in RIGHT kneePain in LEFT kneeDiagnosed arthritis

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