Name ________________________________________ Today's Date



Medical Massage Clinic LLC Winifred Williams, B.S., L.M.T.

4900 Reed Road, Suite 205, Columbus, OH 43220-3186 614-538-8684

Name______________________________________ Today's Date __________________________________

Address_____________________________________ Male__ Female __ Birth date _________________

City/St/Zip __________________________________ Mar ___ Sing ___ Div ___ Wid ___ Sep ___

Phone--Home _____________ Work _______________ Height _______ Weight _________

Who should I contact in case of emergency (Family, Doctor, etc.)? (Optional)Please provide Name and phone number:____________________________________________________________________

How did you hear about us? _______________________________________________________________

Reason for coming/expectation: __________________________________________________________

PLEASE READ AND INITIAL THE FOLLOWING ITEMS. IF YOU HAVE QUESTIONS ABOUT THEM OR WOULD LIKE FURTHER EXPLANATION, PLEASE LET ME KNOW.

________ MASSAGE THERAPY IS NOT A SUBSTITUTE FOR EVALUATION AND TREATMENT BY A DOCTOR.

________ I REQUEST NOTIFICATION OF AN APPOINTMENT CANCELLATION OF 24 HOURS OR MORE BEFORE

THE APPOINTMENT. HOWEVER, IF YOU ARE UNABLE TO DO SO, I MAY NEED TO BILL YOU

FOR THE APPOINTMENT IF I AM UNABLE TO REFILL IT. THANK YOU.

________ FORMS OF PAYMENT ACCEPTED ARE GIFT CERTIFICATE, CASH OR CHECK.

Indicate problem area with a check mark if occasional, circle item if frequent or severe

Head & Neck Digestive Skin

____ Frequent headaches ____ Bloated Stomach ____ Bruises easily

____ Neck pains/tightness ____ Constipation ____ Open cuts/sores

____ Neck lumps or swelling ____ Loose bowels ____ Hypersensitivity

____ ______________________ ____ ____________________ ____ __________________

Eyes Neurological Respiratory

____ Wears glasses ____ Difficulty relaxing ____Breathing difficulty

____ Wears contacts ____ Sleeping difficulties _____ _________________

____ ______________________ ____ ____________________

Musculoskeletal Cardiovascular Female

____ Aching muscle ____ High blood pressure ____ Pregnant

____ Aching joints ____ Low blood pressure ____ Other ____________

____ Lower back pain ____ Swollen feet or ankles ___________________

____ Shoulder pains ____ Leg cramps

____ Painful feet ____ Chest pain

____ ________________________ ____ ______________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Check most frequent body position or movement (check all that apply in a week)

____ Standing ____ Sitting ____ Bending

____ Stooping ____ Lifting ____ Kneeling

____ Leaning forward ____ Unusual head position ____ __________________

____ Repetitive movement ________________________________________________________________

Over please

Page 2

Medical Massage Clinic LLC Winifred Williams, B.S., L.M.T.

4900 Reed Road, Suite 205, Columbus, OH 43220-3186 614-538-8684

Occupation_______________________________ Exercise/Sports _______________________________

Computer use ________ hours per day Telephone use ______ hours per day Headset? ________

Do you use any artificial sweetener? _______ If so, which one(s)?

Neutrasweet( ________ Sweet’N Low ________ Splenda ________ Ace-K,Sunett( ________

(Aspartame) (Saccharin) (Sucralose) (Acesulfame-K)

Neotame ________

(Aspartame plus 3-di-methyl-butyl)

Anything else I should know? _____________________________________________________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download