Only answer what you can, what is relevant to you, and what you are comfortable with sharing.
Date of Initial Visit: ________________________________________________________
Name: ________________________________________________________
Preferred Pronoun: ________________________________________________________
DOB: ________________________________________________________
Age: ________________________________________________________
Occupation: ________________________________________________________
Marital/Relationship Status: ________________________________________________________
REASON FOR VISIT
Primary reason for visit: ________________________________________________________
When did you first notice it? ________________________________________________________
What brought it on? ________________________________________________________
Describe any stressors occurring at the time: ________________________________________________________
What activities provide relief? ________________________________________________________
Is this condition getting worse? YES NO
What makes it worse? ________________________________________________________
Interferes with WORK SLEEP RECREATION
Have you had massage therapy before? YES NO
What type? ________________________________________________________
FAMILY HISTORY
Still living? Cause of death/age of Major health issues
Mother YES NO ________________________________________________________
Father YES NO ________________________________________________________
Sibling(s) YES NO ________________________________________________________
Maternal Grandmother YES NO ________________________________________________________
Maternal Grandfather YES NO ________________________________________________________
Paternal Grandmother YES NO ________________________________________________________
Paternal Grandfather YES NO ________________________________________________________
MEDICAL HISTORY
Are you currently under the care of another health care provider(s)? YES NO
Reason(s): ________________________________________________________
Name(s) of practitioner: ________________________________________________________
Address: ________________________________________________________
Phone: ________________________________________________________
Current medications & supplements: ________________________________________________________
Allergies (specify allergen + reaction): ________________________________________________________
Surgical History: ________________________________________________________
Circle the following symptoms that apply to you:
Headaches + type PAST PRESENT
Numbness in feet or legs while standing PAST PRESENT
Asthma PAST PRESENT
Sore heels when walking PAST PRESENT
Cold hands or feet PAST PRESENT
Anxiety PAST PRESENT
Swollen ankles PAST PRESENT
Depression PAST PRESENT
Sinus conditions, frequent colds PAST PRESENT
Sleep disturbance PAST PRESENT
Seizures PAST PRESENT
Fainting spells PAST PRESENT
Low back pain PAST PRESENT
Muscular tension + location PAST PRESENT
Skin disorders + type PAST PRESENT
Varicose veins, hemorrhoids + location PAST PRESENT
Sciatica PAST PRESENT
Herniated/bulging discs PAST PRESENT
Painful, swollen joints PAST PRESENT
Artificial, missing limbs PAST PRESENT
High or low blood pressure PAST PRESENT
Contact lenses PAST PRESENT
Dentures, partials PAST PRESENT
Cancer +type PAST PRESENT
Other: ________________________________________________________
Surgical history + recent procedures: ________________________________________________________
Hospitalizations: ________________________________________________________
Accidents or traumas: ________________________________________________________
Falls/injuries to sacrum/head/tailbone: ________________________________________________________
Other: ________________________________________________________
REPRODCUTIVE HEALTH HISTORY
Circle Your Method of contraception:
Condoms
IUD
Abstinence
Rhythm method
Fertility awareness
Length of time using method: ________________________________________________________
Circle the following symptoms that apply to you:
Painful urination PAST PRESENT
Difficulty starting or holding urine stream PAST PRESENT
Urinary incontinence or dribbling PAST PRESENT
Blood or pus in urine PAST PRESENT
Weak or interrupted urine flow PAST PRESENT
Pelvic pressure PAST PRESENT
Pain or burning with urination PAST PRESENT
Instable sex drive PAST PRESENT
Nocturnal urination, how often? PAST PRESENT
Pain/discomfort between scrotum & testicles PAST PRESENT
Pain in lower back, especially after intercourse PAST PRESENT
Pain/discomfort in inner thighs RIGHT LEFT
Pain Discomfort in PENIS TESTICLES RECTUM PAST PRESENT
Difficulty in obtaining maintaining erection PAST PRESENT
Frequent bladder or kidney infections, when? PAST PRESENT
Urinary retention PAST PRESENT
Painful ejaculation PAST PRESENT
Results of PSA (prostate specific antigen) test: ________________________________________________________
Date done: ________________________________________________________
Results of sperm count: ________________________________________________________
Date done: ________________________________________________________
Family history of prostate disease? YES NO
Relationship: ________________________________________________________
Family History of cancer? YES NO
Relationship: ________________________________________________________
SEX
Sexually transmitted disease? YES NO
Type: ________________________________________________________
Rate you interest in Sex: HIGH MODERATE LOW NONE
Do you ever or ever had difficulty experiencing orgasms? YES NO
Do you have history of: TRAUMA RAPE INCEST
Did you undergo counseling for this? YES NO
Additional information: ________________________________________________________
DIGESTION + ELIMINATION
Glasses of water/day: ________________________________________________________
Cups of caffeine/day: ________________________________________________________
Tobacco quantity/day: ________________________________________________________
Marijuana quantity/day: ________________________________________________________
Other quantity/day: ________________________________________________________
Have you been under treatment for substance abuse? YES NO
Are you subject to binge eating? YES NO
What foods? ________________________________________________________
Do you experience bloating/gas/burps after eating? YES NO
What foods trigger this? ________________________________________________________
How often are your bowel movements? ________________________________________________________
Constipation? YES NO
Blood in stool? YES NO
Mucus in stool? YES NO
Pain when stooling? YES NO
Other concerns: ________________________________________________________
EMOTIONAL + SPIRITUAL
The most negative emotion you experience is: ________________________________________________________
When do you most often feel this emotion? ________________________________________________________
What hobbies/activities provide you with a sense of accomplishment? ______________________________
Describe your exercise routine: ________________________________________________________
Do you pray or have a spiritual practice? YES NO
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