Health History Form - West Suburban Pain Relief

Safe, Secure, and HIPAA Compliant

Basic Info
Medical History
Dental-Vision
Diet
Work
Home
Sleep
Exercise
Childhood
Cancellation Policy
Informed Consent

Order Number

First Name

Last Name

Cell Phone

Address

City

State

Zip

Chief Complaint

Have You Seen A Doctor For This Condition?

Yes No

Diagnosis

Prior Treatments

Medical History

Injuries/Accidents

Date

Description

Date

Description

Date

Description

Date

Description

Date

Description

Date

Description

Have you been diagnosed or treated for any of the following:

Bulging or Hernated Disc

Yes No

Spinal Stenosis (central)

Yes No

Spinal Stenosis (foraminal)

Yes No

Scoliosis

Yes No

Other Spinal Injury or Disorder

Yes No

Fibromyalgia

Yes No

Carpal Tunnel Syndrome

Yes No

Rotator Cuff Injury

Yes No

Thoracic Outlet Syndrome

Yes No

Fracture of Any Type

Yes No

Osteoporosis, Osteopenia

Yes No

Tear of any Ligament

Yes No

Tendonopathy/Tendonitis/Tendonosis

Yes No

Whiplash

Yes No

TBI, Concussion

Yes No

Diabetes

Yes No

Thyroid Problems

Yes No

IBS-Crohn's Disease-Colitis

Yes No

Pelvic Floor Dysfunction

Yes No

Auto-Immune Disorders

Yes No

Rheumatoid Arthritis

Yes No

Osteoarthritis

Yes No

High Blood Pressure

Yes No

Circulatory Problems

Yes No

Heart Disease

Yes No

Stroke

Yes No

Kidney Disease

Yes No

COPD, Emphysema

Yes No

Cancer

Yes No

Menopause

Yes No

Do you have a primary care doctor?

Yes No

Last visit?

Do you wear shoe orthotics?

Yes No

Are you pregnant?

Yes No

Medications You Currently Take:

medication1

medication2

medication3

medication4

medication5

medication6

Supplements You Currently Take:

supplement1

supplement2

supplement3

supplement4

supplement5

supplement6

Dental and Vision

Do you have a dentist?

Yes No

Last visit?

Clench or grind your teeth?

Yes No

Pain with chewing or yawning?

Yes No

Use a night guard or mouth splint?

Yes No

TMJ, Jaw Joint Disorder?

Yes No

Do you have an eye doctor?

Yes No

Last visit?

Bifocals, Progressive lenses?

Yes No

Do you wear contact lenses?

Yes No

Eyewear at Work

Dietary Habits

Do you eat a balanced diet?

Yes No

Type of diet

Do you consume alcohol?

Yes No

What Kind? How much? How often?

Do you consume caffeine?

Yes No

What Kind? How much? How often?

Do you use tobacco products?

Yes No

What Kind? How much? How often?

Do you use cannabis products?

Yes No

What Kind? How much? How often?

Do you have any food sensitivities?

Yes No

What Kind? How much? How often?

Do you have any allergies?

Yes No

What Kind?

Work Activities

Do you work outside of the home?

Yes No

Occupation

Do you perform repetitive movements?

Yes No

Describe

Are you immobile for long periods?

Yes No

Describe

Do you drive much for work?

Yes No

Describe

Does pain affect you at work?

Yes No

Describe

Do you have a standing desk?

Yes No

Describe

Home Activities

Do you have childcare responsibilities?

Yes No

Describe

Do you have eldercare responsibilities?

Yes No

Describe

Are you immobile for long periods at home?

Yes No

Describe

Favorite Way to Relax

Read on a couch or bed with neck flexed?

Yes No

Describe

Do you clean your own home?

Yes No

Describe

Do you take care of your own yard?

Yes No

Describe

Day to Day Stress Level

Sleep Habits

Sleep Position(s)

Why?

Type of Head Pillow

Why?

Do you use pillows under your knees?

Yes No

Why?

Do you use pillows between your legs/knees?

Yes No

Why?

Do you use pillows to support your arms?

Yes No

Why?

How much sleep do you get?

Do have trouble falling asleep?

Yes No

Do you wake up often during sleep?

Yes No

Do you wake up feeling tired?

Yes No

Have you ever had a sleep study?

Yes No

Were you diagnosed with Sleep Apnea?

Yes No

Have you been advised to use a CPAP?

Yes No

Exercise Habits

Are You Able to Exercise?

Yes No

If Not, Why?

Exercises You Do?

Exercises To Try?

Childhood

Did You Tuck A Foot Under Your Hip?

Yes No

Were you unusually flexible?

Yes No

Did You Play Competitive Sports?

Yes No

Any Developmental Delays?

Yes No

Did You Experience Any Childhood Trauma?

Yes No

Vaccinations

Office Policies

Eased Cancellation Policies for COVID-19

Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater
flexibility to all our clients. We hope this will alleviate any stress and hesitation you have about an upcoming
appointment. If you need to reschedule for whatever reason, and especially if you are not feeling well, we
understand and request for you to please contact us as soon as possible to reschedule. To further support
you, there will be no penalties for cancellations at this time.

Tardiness

Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late
arrivals. Please be on time to your appointment.

Sickness

Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel your
appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour
notice period, the cancellation fee may be waived.

Disease Transmission Risk

I understand that, because massage therapy work involves maintained touch and close physical proximity
over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19.

I understand and agree to these Office Policies.

https://westsubpainrelief.com/office_policies *

COVID-19 Information & Liability Waiver

COVID-19 Information

I have not had fever of over 100°F for the last 48 hours.

https://westsubpainrelief.com/informed_consent *

I do not now, and have not recently had, any respiratory or flu symptoms, sore throat, or shortness of breath.

https://westsubpainrelief.com/informed_consent *

I have not been been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms.

https://westsubpainrelief.com/informed_consent *

I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

https://westsubpainrelief.com/informed_consent *

Schedule An Appointment

When your appointment time arrives, visit our HIPAA-compliant, Secure Video Chat:

Myofascial Coaching with

Janet Burson CMTPT

Begin Session

Telemedicine by

Doxy.me

Safe, Secure, and HIPAA Compliant

Basic Info
Medical History
Dental-Vision
Diet
Work
Home
Sleep
Exercise
Childhood
Cancellation Policy
Informed Consent

Phone

First Name

Last Name

Cell Phone

Address

City

State

Zip

Chief Complaint

Have You Seen A Doctor For This Condition?

Yes No

Diagnosis

Prior Treatments

Medical History

Injuries/Accidents

Date

Description

Date

Description

Date

Description

Date

Description

Date

Description

Date

Description

Have you been diagnosed or treated for any of the following:

Bulging or Hernated Disc

Yes No

Spinal Stenosis (central)

Yes No

Spinal Stenosis (foraminal)

Yes No

Scoliosis

Yes No

Other Spinal Injury or Disorder

Yes No

Fibromyalgia

Yes No

Carpal Tunnel Syndrome

Yes No

Rotator Cuff Injury

Yes No

Thoracic Outlet Syndrome

Yes No

Fracture of Any Type

Yes No

Osteoporosis, Osteopenia

Yes No

Tear of any Ligament

Yes No

Tendonopathy/Tendonitis/Tendonosis

Yes No

Whiplash

Yes No

TBI, Concussion

Yes No

Diabetes

Yes No

Thyroid Problems

Yes No

IBS-Crohn's Disease-Colitis

Yes No

Pelvic Floor Dysfunction

Yes No

Auto-Immune Disorders

Yes No

Rheumatoid Arthritis

Yes No

Osteoarthritis

Yes No

High Blood Pressure

Yes No

Circulatory Problems

Yes No

Heart Disease

Yes No

Stroke

Yes No

Kidney Disease

Yes No

COPD, Emphysema

Yes No

Cancer

Yes No

Menopause

Yes No

Do you have a primary care doctor?

Yes No

Last visit?

Do you wear shoe orthotics?

Yes No

Are you pregnant?

Yes No

Medications You Currently Take:

medication1

medication2

medication3

medication4

medication5

medication6

Supplements You Currently Take:

supplement1

supplement2

supplement3

supplement4

supplement5

supplement6

Dental and Vision

Do you have a dentist?

Yes No

Last visit?

Clench or grind your teeth?

Yes No

Pain with chewing or yawning?

Yes No

Use a night guard or mouth splint?

Yes No

TMJ, Jaw Joint Disorder?

Yes No

Do you have an eye doctor?

Yes No

Last visit?

Bifocals, Progressive lenses?

Yes No

Do you wear contact lenses?

Yes No

Eyewear at Work

Dietary Habits

Do you eat a balanced diet?

Yes No

Type of diet

Do you consume alcohol?

Yes No

What Kind? How much? How often?

Do you consume caffeine?

Yes No

What Kind? How much? How often?

Do you use tobacco products?

Yes No

What Kind? How much? How often?

Do you use cannabis products?

Yes No

What Kind? How much? How often?

Do you have any food sensitivities?

Yes No

What Kind? How much? How often?

Do you have any allergies?

Yes No

What Kind?

Work Activities

Do you work outside of the home?

Yes No

Occupation

Do you perform repetitive movements?

Yes No

Describe

Are you immobile for long periods?

Yes No

Describe

Do you drive much for work?

Yes No

Describe

Does pain affect you at work?

Yes No

Describe

Do you have a standing desk?

Yes No

Describe

Home Activities

Do you have childcare responsibilities?

Yes No

Describe

Do you have eldercare responsibilities?

Yes No

Describe

Are you immobile for long periods at home?

Yes No

Describe

Favorite Way to Relax

Read on a couch or bed with neck flexed?

Yes No

Describe

Do you clean your own home?

Yes No

Describe

Do you take care of your own yard?

Yes No

Describe

Day to Day Stress Level

Sleep Habits

Sleep Position(s)

Why?

Type of Head Pillow

Why?

Do you use pillows under your knees?

Yes No

Why?

Do you use pillows between your legs/knees?

Yes No

Why?

Do you use pillows to support your arms?

Yes No

Why?

How much sleep do you get?

Do have trouble falling asleep?

Yes No

Do you wake up often during sleep?

Yes No

Do you wake up feeling tired?

Yes No

Have you ever had a sleep study?

Yes No

Were you diagnosed with Sleep Apnea?

Yes No

Have you been advised to use a CPAP?

Yes No

Exercise Habits

Are You Able to Exercise?

Yes No

If Not, Why?

Exercises You Do?

Exercises To Try?

Childhood

Did You Tuck A Foot Under Your Hip?

Yes No

Were you unusually flexible?

Yes No

Did You Play Competitive Sports?

Yes No

Any Developmental Delays?

Yes No

Did You Experience Any Childhood Trauma?

Yes No

Vaccinations

Office Policies

Eased Cancellation Policies for COVID-19

Tardiness

Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late
arrivals. Please be on time to your appointment.

Sickness

Disease Transmission Risk

I understand and agree to these Office Policies.

https://westsubpainrelief.com/office_policies *

COVID-19 Information & Liability Waiver

COVID-19 Information

I have not had fever of over 100°F for the last 48 hours.

https://westsubpainrelief.com/informed_consent *

I do not now, and have not recently had, any respiratory or flu symptoms, sore throat, or shortness of breath.

https://westsubpainrelief.com/informed_consent *

I have not been been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms.

https://westsubpainrelief.com/informed_consent *

Schedule An Appointment

When your appointment time arrives, visit our HIPAA-compliant, Secure Video Chat:

Start a telemedicine call with