Momentum Healthcare, LLC
575 Boylston St. 4th Floor Boston, MA 02116
New Patient History
Date:
Full Name_________________________________________________________ Phone____________________________
DOB:_________________
Address:______________________________________________________________________________________________________________________________________________
Marital Status: M S W D
Children? (#, ages)______________________________________________
Occupation:__________________________________________
Are you:
How is most of your day spent?
Standing
Have you ever been to a massage therapist? No
Ever had a vehicle crash injury?
No
Ever had a work-related injury?
No
Sitting
Yes
Yes
Yes
Right Handed
Left Handed
Ambidextrous
Walking
Lifting/Carrying
When/Why?______________________________________________________________
When?_____________________________________________________________________
When?_____________________________________________________________________
Current Complaints or Issues that Brought You Here:
Describe each complaint/issue. When did it begin? How long have you had it?
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Have you seen any other healthcare providers (MD, DC, PT, etc) for this condition?
No
Yes
Please describe:_______________________________________________________________________________________________________________________________
Is your condition:
Improving
Are symptoms interfering with:
Work
Worsening
Sleep
Sports
The Same
Home Other
Does your pain wake you from sleep? No
Yes
Describe Each Problem Area Separately (e.g., “neck pain”, “shoulder”, “lower back”)
Problem Area #1:________________________________________________________________________________________________________________________________________
Are your symptoms?:
Constant
Off and On
Grade your pain from 0 (no pain) to 10 (worst imaginable): 0 1 2 3 4 5 6 7 8 9 10
What provokes or alleviates your symptoms?_____________________________________________________________________________________________
Problem Area #2:________________________________________________________________________________________________________________________________________
Are your symptoms?:
Constant
Off and On
Grade your pain from 0 (no pain) to 10 (worst imaginable): 0 1 2 3 4 5 6 7 8 9 10
What provokes or alleviates your symptoms?_____________________________________________________________________________________________
Problem Area #3:________________________________________________________________________________________________________________________________________
Are your symptoms?:
Constant
Off and On
Grade your pain from 0 (no pain) to 10 (worst imaginable): 0 1 2 3 4 5 6 7 8 9 10
What provokes or alleviates your symptoms?_____________________________________________________________________________________________
Momentum Healthcare, LLC
575 Boylston St. 4th Floor Boston, MA 02116
Momentum Healthcare, LLC
575 Boylston St. 4th Floor Boston, MA 02116
Past Medical History:
Please circle any of the following conditions if you are currently or have been previously diagnosed:
Back Pain
Neck Pain
Numbness/Tingling
Sciatica
Jaw Pain/TMJ
Headaches
Shoulder Pain
Elbow/Arm Pain
Carpal Tunnel Syn.
Knee Problems
Foot or Ankle Pain
Wrist or Hand Pain
Sprained Ankle(s)
Concussion
Knocked Unconscious
Eye Injuries
Sinus Problems
Shortness of Breath
Dizziness
Chest Pains
High Blood Pressure
Arteriosclerosis
Constipation
Sleep Disorder
Fractures
Osteoporosis (‘penia)
Irritable Bowel
Digestion Problems
Heart Problem
Kidney Problem
Thyroid Problem
Liver Problem
Gall Bladder Problem
Lung Disease
Menstrual Irregularity
Menstrual cramps
Prostate Problem
Uterus/Ovary Problems
Skin Diseases
HIV +
Hepatitis
Mononucleosis
Anemia
Excessive Thirst
Night Sweats
Weight Loss
Frequent Urination
Diabetes
Limb Edema
Bruise Easily
Chronic Fatigue
Lyme’s Disease
Nervousness
Depression
Anxiety
Chemical Addiction
Eating Disorder
Allergies
Difficulty Breathing
Asthma
Chronic Cough
Cancer
Lumps/Tumors
Bursitis
Other:
List ALL surgeries, major injuries, illnesses, or hospitalizations that you have had in the past. Do you have any residual issues?
____________________________________________________________________________________________________________________________________________________________
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____________________________________________________________________________________________________________________________________________________________
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List ALL medicines, herbs/vitamins you currently take (attach or e-mail a list if you prefer):
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
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Family/Social History:
Do you smoke cigarettes?
Do you drink alcohol
Daily
No
Yes
Socially
How much?
Seldom
Never
Describe your diet:
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
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Describe your regular exercise program:
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Any significant family history of:
Diabetes
Cancer
Heart Disease
Other:__________________________________________________
_________________________________________________________________
___________________________________________________________
Client Signature
Date
Momentum Healthcare, LLC
575 Boylston St. 4th Floor Boston, MA 02116
Momentum Healthcare, LLC
I understand that the massage at Momentum Healthcare, LLC is for the purpose of stress reduction,
pain reduction, relief from muscle tension, increasing circulation.
I understand that the massage therapist does not diagnose illness or disease and does not prescribe
medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy.
I understand that massage therapy is not a substitute for medical care and that it is recommended
that I work with my primary caregiver for any condition I may have.
I have stated all my known physical conditions and medications, and I will keep the massage therapist
updated on any changes.
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Signature
_____________________________________________
Printed name
_____________________________________________
E-Mail
____________________________
Date