"Health & Wellness Report Template - Integrative Touch and Bodywork"

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HEALTH & WELLNESS REPORT
Name:_____________________________________________________________________ Date:_______________________
Phone:_________________________________________ Date of Injury:_________________________________________
1.
Are you currently experiencing any of the following symptoms? If yes, please explain.
Dull Achy Pain
Yes
No
Swelling or Inflammation
Yes
No
Tenderness (w/ touch)
Yes
No
Numbing or Tingling
Yes
No
Soreness (w/o touch)
Yes
No
Allergies
Yes
No
Stiffness
Yes
No
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Key:
P = Pain / Tenderness / Soreness
S = Stiffness of Joint or Muscles
I = Inflammation or Swelling
N = Numbness or Tingling
Identify current symptomatic areas
of your body by placing the
corresponding letter(s) on the
figure provided
Circle or shade around each letter
to illustrate the area affected by
these symptoms
On the rating scale below, mark
the point which best represents the
overall intensity of your symptom(s)
No
Mild
Moderate
Severe
Excruciating
911
Pain
Pain
Pain
Pain
Pain
Pain
2. For this session, what are your goals for attaining health and how can we best assist you?
____________________________________________________________________________________________________________
3. Have there been any changes (improvements or deterioration) in your condition since your last
visit? List any new illnesses, injuries, activities or health concerns that are related to current condition:
____________________________________________________________________________________________________________
4. List daily activities affected by symptoms
work, exercise, hobbies, etc:
____________________________________________________________________________________________________________
5.
List medications or pain relievers taken recently for this condition (Rx or over the counter):
____________________________________________________________________________________________________________
6. I have provided all my known medical information. I acknowledge that massage therapy is not a
substitute for medical diagnosis and treatment. I give my consent to receive treatment.
Signature:____________________________________________________________________ Date:_______________________
ITandB.com
/ 5030 S Hwy 17-92 / Suite B / Casselberry, FL 32707 / 407.332.6842
HEALTH & WELLNESS REPORT
Name:_____________________________________________________________________ Date:_______________________
Phone:_________________________________________ Date of Injury:_________________________________________
1.
Are you currently experiencing any of the following symptoms? If yes, please explain.
Dull Achy Pain
Yes
No
Swelling or Inflammation
Yes
No
Tenderness (w/ touch)
Yes
No
Numbing or Tingling
Yes
No
Soreness (w/o touch)
Yes
No
Allergies
Yes
No
Stiffness
Yes
No
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Key:
P = Pain / Tenderness / Soreness
S = Stiffness of Joint or Muscles
I = Inflammation or Swelling
N = Numbness or Tingling
Identify current symptomatic areas
of your body by placing the
corresponding letter(s) on the
figure provided
Circle or shade around each letter
to illustrate the area affected by
these symptoms
On the rating scale below, mark
the point which best represents the
overall intensity of your symptom(s)
No
Mild
Moderate
Severe
Excruciating
911
Pain
Pain
Pain
Pain
Pain
Pain
2. For this session, what are your goals for attaining health and how can we best assist you?
____________________________________________________________________________________________________________
3. Have there been any changes (improvements or deterioration) in your condition since your last
visit? List any new illnesses, injuries, activities or health concerns that are related to current condition:
____________________________________________________________________________________________________________
4. List daily activities affected by symptoms
work, exercise, hobbies, etc:
____________________________________________________________________________________________________________
5.
List medications or pain relievers taken recently for this condition (Rx or over the counter):
____________________________________________________________________________________________________________
6. I have provided all my known medical information. I acknowledge that massage therapy is not a
substitute for medical diagnosis and treatment. I give my consent to receive treatment.
Signature:____________________________________________________________________ Date:_______________________
ITandB.com
/ 5030 S Hwy 17-92 / Suite B / Casselberry, FL 32707 / 407.332.6842