Intake

__ Abdominal pain

__ Allergies

__ Anemia

__ Appendicitis

__ Arthritis

__ Asthma

__ Athletes foot

__ Blood clots

__ Blood transfusion

__ Bursitis

__ Blurred vision

__ Bronchitis

Cancer/tumor:

__ -- benign

__ – malignant

__ Cerebral palsy

__ Chest pain

__ Chicken pox

__ Chronic pain

__ Concussion

__ Congested breasts

__ Depression

__ Diabetes

__ Difficulty breathing

__ Disk problems

__ Dizziness

__ Ear infection

__ Ear noise

__ Eczema

__ Edema

__ Emphysema

__ Enlarged glands

__ Epilepsy

__ Eye disease

__ Fever blisters

__ Gallbladder trouble

__ Gas &/or bloating

__ Goiter

__ Gout

__ Headache

__ Head injury

__ Heart disease

__ Hepatitis

__ Hernia

__ Herpes

__ HIV

__ High or low blood pressure

__ Hot flashes

__ Irregular heartbeat

__ Kidney problem

__ Liver disease

__ Loss of memory

__ Loss of sensation/

numbness

__ Lupus

__ Malaria

__ Measles

__ Migraines

__ Miscarriage

__ Mononucleosis

__ Mumps

__ Multiple sclerosis

__ Nausea

__ Neuralgia or neuritis

__ Numbness, tingling

__ Osteoporosis

__ Painful menstruation

__ Parkinsonism

__ Pneumonia

__ Polio or Post-polio

__ Poor circulation

__ Rashes

__ Rheumatic fever

__ Sciatica

__ Scoliosis

__ Seizures

__ Shooting pains

__ Shortness of breath

__ Sleep disturbance

__ Stroke

__ Swollen ankles

__ Tension/anxiety

__ Tuberculosis

__ Ulcers

__ Varicose veins

__ Whiplash

__ Yellow Jaundice

Helene Baradat-Thompson, LMP Confidential Client History, page 3 of 7

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Have you ever:

Broken a bone? ¨ No ¨ Yes

Had strains or sprains? ¨ No ¨ Yes

Been in an auto accident? ¨ No ¨ Yes

Been struck unconscious? ¨ No ¨ Yes

Been hospitalized? ¨ No ¨ Yes

Used a cane, crutch, or other support? ¨ No ¨ Yes

Describe previous injuries/accidents: Dates:

¨ Automobile accident(s): _________________________________________ __________

¨ On-the-job injury: ______________________________________________ __________

¨ Sports injury: _________________________________________________ __________

¨ Falls: _______________________________________________________ __________

¨ Other: _________________________________________________________________

List any vitamins, minerals, herbs, or prescription drugs you're taking:

____________________________________________________________________________

Do you drink coffee or other caffeinated beverages? ¨ No ¨ Yes: _____ ounces per day

Describe any usage of nonprescription

or recreational drugs: _________________________________________________________

Do you smoke cigarettes? ¨ No ¨ Yes: _____ packs per day

Number of pregnancies ___ Are you pregnant now? ¨ No ¨ Yes: # weeks ____

List any surgeries and dates: _____________________________________________________

Health care providers seen for treatment:

¨ Primary care physician:___________________________________ _________________

¨ Other: _________________________________________________________________

When was your last physical examination? __________________________________

Have you been diagnosed with a particular condition? ¨ No ¨ Yes

If yes, please explain:

____________________________________________________________________________

Have you had massage or any other bodywork before? ¨ No

¨ Yes: date of last session:_________

Helene Baradat-Thompson, LMP Confidential Client History, page 4 of 7

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Do stiff or painful muscles or joints trouble you? ¨ No ¨ Yes

Are your joints ever swollen? ¨ No ¨ Yes

Do pains in your back or shoulder trouble you? ¨ No ¨ Yes

Are your feet often painful? ¨ No ¨ Yes

Do you have any skin problems? ¨ No ¨ Yes

Does your skin itch or burn? ¨ No ¨ Yes

Do you have trouble stopping even a small cut from bleeding? ¨ No ¨ Yes

Do you bruise easily? ¨ No ¨ Yes

Do you ever faint or feel faint? ¨ No ¨ Yes

Is any part of your body always numb? ¨ No ¨ Yes

Have you ever had seizures or convulsions? ¨ No ¨ Yes

Has your handwriting changed lately? ¨ No ¨ Yes

Do you have a tendency to shake or tremble? ¨ No ¨ Yes

Have you gained or lost much weight recently? ¨ No ¨ Yes

Do you have a tendency to be too hot or too cold? ¨ No ¨ Yes

Have you lost your interest in eating lately? ¨ No ¨ Yes

Do you always seem to be hungry? ¨ No ¨ Yes

Are you more thirsty than usual lately? ¨ No ¨ Yes

Are there any swellings in your armpits or groin? ¨ No ¨ Yes

Do you seem exhausted or fatigued most of the time? ¨ No ¨ Yes

Do you have difficulty either falling asleep or staying asleep? ¨ No ¨ Yes

Do you drive a motor vehicle more than 25,000 miles a year? ¨ No ¨ Yes

How often do you use seatbelts when riding in cars? ____________

List any country outside the United States you have visited in the past six months:

Do you have any dental problems? ¨ No ¨ Yes

Do you have any swellings on your gums or jaws? ¨ No ¨ Yes

Is your tongue ever sore? ¨ No ¨ Yes

Is it difficult or painful for you to swallow? ¨ No ¨ Yes

Do you ever bite your tongue when eating? ¨ No ¨ Yes

Have you experienced any changes in taste? ¨ No ¨ Yes

Do you ever experience blurry vision? ¨ No ¨ Yes

Is your eyesight worsening? ¨ No ¨ Yes

Do you ever see double? ¨ No ¨ Yes

Do you ever see a halo? ¨ No ¨ Yes

Do you have eye pains or itching? ¨ No ¨ Yes

Do your eyes water? ¨ No ¨ Yes

Helene Baradat-Thompson, LMP Confidential Client History, page 5 of 7

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Do you have hearing difficulties? ¨ No ¨ Yes

Do you experience earaches? ¨ No ¨ Yes

Do you have running ears? ¨ No ¨ Yes

Do you have buzzing in your ears? ¨ No ¨ Yes

Do you get motion sickness? ¨ No ¨ Yes

Is your nose ever congested? ¨ No ¨ Yes

Does your nose often run? ¨ No ¨ Yes

Do you experience sneezing spells? ¨ No ¨ Yes

Do you have frequent headcolds? ¨ No ¨ Yes

Does your nose bleed? ¨ No ¨ Yes

Do you have a sore throat? ¨ No ¨ Yes

Is your voice hoarse? ¨ No ¨ Yes

Do you wheeze or gasp for air? ¨ No ¨ Yes

Do you have coughing spells? ¨ No ¨ Yes

Do you cough up phlegm? ¨ No ¨ Yes

Do you cough up blood? ¨ No ¨ Yes

Do you get chest colds? ¨ No ¨ Yes

Do you experience excessive sweating and/or night sweats? ¨ No ¨ Yes

Do you have high blood pressure? ¨ No ¨ Yes

Do you ever experience your heart racing? ¨ No ¨ Yes

Do you get chest pains? ¨ No ¨ Yes

Do you have dizzy spells? ¨ No ¨ Yes

Are you ever short of breath? ¨ No ¨ Yes

Do you ever need more pillows to breathe? ¨ No ¨ Yes

Do you ever have swollen legs or ankles? ¨ No ¨ Yes

Do you have leg cramps? ¨ No ¨ Yes

Have you ever been told you have a heart murmur? ¨ No ¨ Yes

Do you frequently get up at night to urinate? ¨ No ¨ Yes

Do you urinate more than five or six times a day? ¨ No ¨ Yes

Do you wet your pants or wet your bed? ¨ No ¨ Yes

Have you ever had burning or pains when you urinate? ¨ No ¨ Yes

Has your urine ever been brown, black or bloody? ¨ No ¨ Yes

Do you have difficulty starting your urine flow? ¨ No ¨ Yes

Do you have a constant feeling that you have to urinate? ¨ No ¨ Yes

Are you troubled by heartburn? ¨ No ¨ Yes

Do you feel bloated after eating? ¨ No ¨ Yes

Does belching trouble you? ¨ No ¨ Yes

Do you suffer discomfort in the pit of your stomach? ¨ No ¨ Yes

Do you easily become nauseated (feel like vomiting)? ¨ No ¨ Yes

Have you ever vomited blood? ¨ No ¨ Yes

Helene Baradat-Thompson, LMP Confidential Client History, page 6 of 7

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Are you constipated more than twice a month? ¨ No ¨ Yes

Are your bowel movements ever loose for more than one day? ¨ No ¨ Yes

Are your bowel movements ever black or bloody? ¨ No ¨ Yes

Are your bowel movements ever gray in color? ¨ No ¨ Yes

Do you suffer pains when you move your bowels? ¨ No ¨ Yes

Have you had any bleeding from your rectum? ¨ No ¨ Yes

Are your very nervous around strangers? ¨ No ¨ Yes

Do you find it hard to make decisions? ¨ No ¨ Yes

Do you find it hard to concentrate or remember? ¨ No ¨ Yes

Do you have difficulty relaxing? ¨ No ¨ Yes

Are you troubled by frightening dreams or thoughts? ¨ No ¨ Yes

Do you have tendency to worry a lot? ¨ No ¨ Yes

Do you usually feel lonely or depressed? ¨ No ¨ Yes

Do you often cry? ¨ No ¨ Yes

Do you have a strong dislike for criticism? ¨ No ¨ Yes

Do you lose your temper often? ¨ No ¨ Yes

Do little things often annoy you? ¨ No ¨ Yes

Are you disturbed by any work or family problems? ¨ No ¨ Yes

Are you having sexual difficulties? ¨ No ¨ Yes

For women only:

1. What was the date of your last menstrual period? _____/_____/_____

2. Are you past menopause or have you had a hysterectomy? ¨ No ¨ Yes

If yes, have you noticed any bleeding since? ¨ No ¨ Yes

(Please now skip to question #6.)

3. Was your last menstrual period normal? ¨ No ¨ Yes

4. Do you have heavy bleeding with your periods? ¨ No ¨ Yes

5. Have you had bleeding between your periods? ¨ No ¨ Yes

6. Do you every have bleeding after intercourse? ¨ No ¨ Yes

7. Have you had complications with any type of birth control? ¨ No ¨ Yes

8. Have you ever noticed any lumps or pains in your breasts? ¨ No ¨ Yes

9. When was your last Pap test? Month:__________ Year: _____

For men only:

Is your urine stream very weak and slow? ¨ No ¨ Yes

Has a doctor ever told you that you have prostate trouble? ¨ No ¨ Yes

Have you had any burning or discharge from your penis? ¨ No ¨ Yes

Are there any swellings or lumps on your testicles? ¨ No ¨ Yes

Do your testicles get painful? ¨ No ¨ Yes

Helene Baradat-Thompson, LMP Confidential Client History, page 7 of 7

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What do you expect from the session today? ________________________________________

____________________________________________________________________________

Do you have any specific areas you would like to work on? _____________________________

____________________________________________________________________________

Are there any particularly sensitive or painful areas? ¨ No ¨ Yes: please use the

attached drawing to identify those areas.

Check any of the following that describes the pain:

Where do you feel tension in your body? ___________________________________________

How do you feel in your body now? _______________________________________________

Is there anything else that you feel I should know about you? ___________________________

The information given on these pages is complete and correct to the best of my knowledge and on future visits, I will inform Helene Baradat-Thompson, LMP, CTP of any changes in my health. It is my choice to receive manual therapy and I give my consent to receive treatment.