Medical Massage Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required First Name * Last Name * Email * Phone * How do you prefer we contact you to set up your first appointment? * by phoneby email If phone contact is preferred, please indicate the best time(s) to reach you. Clinical Intake Form for Medical Massage Please take the time to complete this form at least 24 hours prior to your appointment. Answers to these questions allow us to provide the best assessment and treatment for your initial session. There is no limit to the length of your responses when explanations might be needed. If you have any questions, feel free to contact us or call 941-755-0406. General Questions What is your primary complaint? * How long have you had this/these symptom(s)? * What symptoms do you have right now? * When and how did everything start? * Have you seen anyone, especially your physician, and has any diagnosis already been established? Were any tests (x-ray, MRI, CT, Nerve Conduction Study, etc) done? * What treatments, if any, were used? * Were other health conditions or medications eliminated by the primary physician as potential causes of your symptoms? * Have you experienced any previous traumas? * Do any family members have similar problems? * yesnodon't know Pain Evaluation How would you describe the pain you have or had? * Examples: sharp, aching, burning, pulsating or describe in your own words. Do you feel pain locally? Do you feel pain radiating to any meighboring part of the body? * local painsome radiationdistant radiation Check all that apply. Do you have the sensation of spreading pain? * yesnoI'm not sure Do you notice if the pain you have is accompanied by: * Check all that apply. headachenauseasweating"goose bumps"change in body temperaturenone of these Do you have the sensation the original pain triggers pain in other parts of your body? * My pain is local only - no radiating/other pain.radiation pain - travels from original spot out.referred pain - skips from the original spot to a different area. After you wake up, do you feel pain or rested? * painrestedno pain, but not rested Do you feel the pain is getting worse by late afternoon / evening? * worse by late afternoon / evening.levels or stays consistent throught the day.not sure. Do you have night pain? * yesyes, but no more than once a weeksometimesno Do you have difficulties falling asleep? * yesyes, but no more than once a weeksometimesno Do you wake up during the night? * yesno If you answered yes, how often? How is the pain you feel affected by your movement? * increases pain intensitydecreases pain intensityhas no effect on pain intensity How do you grade your pain intensity on a scale of 1 - 10? * 1 - no pain, 10 - severe / unbearable You are almost finished! Just a few more questions and you'll be on your way to making your medical massage appointment. Evaluation of Sensory Abnormalities Have you had or do you currently have sensations of tingling or numbness in any part of the body? * Evaluation of Motor Abnormalities Do you feel any restriction in your range of motion? If yes, explain. * Do you feel any muscle weakness? If yes, explain. * Is there anything else you think we should know? When you click the submit button, our Medical Massage Therapist Team will review your responses and contact you within 24 hours of your submittal. Congratulations on taking the first step in addressing your pain with medical massage and we look forward to meeting you soon!