New Patient Form Massage Company Patient Name: Date: Have you ever been diagnosed or told you to have any of the following? 1. High blood pressure Yes No 2. Hardening of the arteries (arteriosclerosis) Yes No 3. Diabetes Yes No 4. Tuberculosis Yes No 5. Cancer Yes No Where? 6. Heart or blood diseases Yes No 7. Bone spurs on the neck bones (cervical sprain) Yes No 8. Whiplash injury (flexion-extension injury, cervical sprain) Yes No 9. Have you or any of your relatives suffered a stroke? Yes No 10. Were you ever a smoker? Yes No From To 11. Do you take medication on a regular basis? Yes No 12. Visual disturbances (blurring, loss, double vision) Yes No 13. Hearing disturbances (loss, ringing, other noise) Yes No 14. Slurred speech or other speech problems Yes No 15. Difficulty swallowing Yes No 16. Dizziness Yes No 17. Loss of consciousness, even momentary blackouts Yes No 18. Numbness, loss of sensation, loss of strength or weakness in the face, fingers, hands, arms, legs, or any other parts of the body? Yes No 19. Sudden collapse without loss of consciousness Yes No Indicate the severity of your pain (0 - No Pain | 10 - Extreme Pain) 1 2 3 4 5 6 7 8 9 10
