CHRISTINA M. MITCHELL, LMT, LLC - THERAPEUTIC MASSAGE
FL Lic. # MA49769, Establishment Lic.#MM22673
CLIENT/PATIENT INFORMATION DATE :__________________________
NAME: ______________________ DOB: ______________AGE:_____ MARITAL STATUS: ____________
ADDRESS: _______________________________CITY:__________________STATE:_____ZIP:_________
PHONE CELL: __________________ PHONE HOME:__________________PHONE OTHER:______________
PROFESSION: __________________________EMAIL:__________________________________________
EMERGENCY CONTACT NAME/PHONE: _______________________________________________________
PHYSICIAN: ______________________________________________ PHONE: ______________________
REASON FOR VISIT: _________________________________________________________
AREAS OF PAIN OR DISCOMFORT-SCALE 0/10:______________________________________________
WHAT ARE YOUR EXPECTATIONS? _______________________________________________________
MEDICATIONS: ________________________________________________________________________
SYMPTOMS AND CONDITIONS
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Abdominal Pain |
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Diabetes Non-Insulin |
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Nervousness |
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Abdominal Aortic Aneurysm |
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Difficulty Breathing |
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Tunnel Osteoporosis |
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Allergies |
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Dizziness or Vertigo |
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Pain Pregnancy |
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Arthritis |
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Edema |
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Problems Respiratory Illness |
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Asthma |
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Epilepsy or Seizures |
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Sciatica |
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Auto Accident |
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Fainting |
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Scoliosis |
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Auto Immune Illness |
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Fibromyalgia Syndrome |
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Shortness of Breath |
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Back Pain |
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Headaches or Migraines |
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Sinus Congestion |
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Blood Clots |
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Heart Problems |
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Skin Disorders |
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Broken Bones |
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Herniated Disc |
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Spinal Injury |
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Bursitis |
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Hormonal Problems |
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Sprains, Falls or Stitches |
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Cancer |
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High Blood Pressure |
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Stroke |
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Carpel Tunnel |
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HIV/AIDS |
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Vertigo Surgery |
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Chest Pain |
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Hysterectomy |
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Swelling or Edema |
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Circulation Problems |
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Joint Replacement |
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Tendonitis |
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Colitis |
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Knee Surgery |
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Thyroid Problem |
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Congestive Heart Failure |
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Laminectomy |
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TMJ |
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Constipation |
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Ligament Tears |
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Tuberculosis |
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Coccyx Injury |
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Lymph Node Removal |
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Ulcer |
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Contagious Diseases |
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Low Blood Pressure |
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Varicose Veins |
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Diabetes Insulin |
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Neck Injury or Whiplash |
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Other:______________ Please Explain:
PERMISSION TO TREAT: SIGNATURE: ________________________________ DATE: __________________
1000 Tamiami Trail N., Suite 501, Naples, Florida 34102 – 239-293-0960 www.bestbodymassage.com