Massage Therapy Paperwork

Today's Date
MM slash DD slash YYYY
Full Legal Name*
First Last
Nickname (optional)
First Last
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Sex:*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Minor?*
- Yes
- No
If yes, parent's full legal name:
First Last
Parent's Date of Birth:
MM slash DD slash YYYY
Occupation:
How did you hear about us?
Phone Number (Mobile):*
Phone Number (Home):
Phone Number (Work):
Email Address:*
Contact Preference:
- Mobile
- Home
- Work
- Email
Emergency Contact Name:
First Last
Emergency Contact Phone:
Emergency Contact Relationship:
Medical History
Medications:
List names and dosages
Past Surgical History:
List date, location, surgeon's name, type of surgery, any complications
Imaging History (X-Ray, MRI, etc):
List date, area, type of imaging, and findings
Current Complaints (if any):
List all, beginning with PRIMARY complaint and locations
When and how did your primary complaint start?
Describe Chief Complaint Pain:
- Aching
- Burning
- Bruising
- Shooting
- Stabbing
- Inflammation/Swelling
- Sharp
- N/A
Check all that apply.
Describe Related Sensations:
- Pins and Needles
- Numb / No Feeling
- N/A
Check all that apply
Knee Symptoms:
- Locking
- Instability / Giving Way
- Pain going up/down stairs
- Buckling
- Swelling
- N/A
Check all that apply.
Shoulder Symptoms:
- Difficulty raising arm above 90 degrees
- Difficulty with lifting/carrying
- Numbing/tingling below elbow
- N/A
Check all that apply.
Problems with movement due to chief complaint:
- Pain
- Inflexibility
- Stiffness
- Spasms/Cramping
- Limping
- N/A
Check all that apply
When was the onset of this problem?
Was the onset gradual or sudden?
On a scale of 0-10, rate your pain:
What increases pain?
What decreases pain?
Have you received treatment before?
If so, please describe. Otherwise, please type "N/A"
Please describe any home care you have received:
If none, please type "N/A"

Medical History