Today's Date - Medical Massage Clinic
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? _____________________________________________________________
................
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