here

Personal Health Questionnaire DATE _____________________
Name
Work# _____________________________
________________________________________
Home#_____________________________
Cell# _____________________________
Home or Mailing Address
(indicate which # is best by an asterisk * )
____________________________________________ Age________
Birthdate_____________
____________________________________________ Life Occupation________________________
Email________________________________________
Emergency Contact: Name______________________________ Phone:_______________________
Referred by: __________________________________________ Onset or Date of Injury:___________
REASON FOR TREATMENT:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
MARK PROBLEM AREAS on diagram below:
DEGREE OF CURRENT SENSATION:
(Circle) None <
1
2
3
4
Gigi Willett DMIc AATc LMT Manual Therapy
5
6
7
8
9 10 > Most
1780 South Bellaire Street Suite 303 Denver Colorado 80222
phone: 720.732.5201
DESCRIBE SENSATION or SYMPTOM:
Circle all that apply: Sharp, Numb, Ache, Tingling, Stiffness, Swelling, Burning, Stress or Other
__________________________________________________________________________________
Constant? Y _N _
Intermittent? Y _ N _ Duration______________
Since Onset, Has Symptom? Increased__ Decreased__ Stayed the Same__
MODIFYING FACTORS:
What increases sensation? (change of posture, walk, sit, stand, etc.)
__________________________________________________________________________________
What helps sensation? (ice, heat, change of posture, activity, etc.)
__________________________________________________________________________________
TREATMENT AND TESTS:
What Treatment Have You Had For This?
___________________________________________________________________________________
___________________________________________________________________________________
What Medical Diagnostic Tests Have You Had For This? MRI, PetScan, X-ray, Ultrasound, EMG, EKG,
EEG, Endoscopy, etc.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
MARK and label any current skin issues, bruises, cuts, hives, shingles, etc. on diagram below:
Gigi Willett DMIc AATc LMT Manual Therapy
1780 South Bellaire Street Suite 303 Denver Colorado 80222
phone: 720.732.5201
Your GOALS for treatment: (What daily activities would you like to participate in you may have eliminated
or postponed?)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
MARK ALL Surgical Incision Sites, Laparoscopies, Epidurals, Cortisone, Botox or other Injections on
diagram below:
List ALL Surgeries and Hospitalizations:
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
List ALL major Accidents and Injuries, (Broken Bones, Whiplash, etc). (including all during childhood):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Gigi Willett DMIc AATc LMT Manual Therapy
1780 South Bellaire Street Suite 303 Denver Colorado 80222
phone: 720.732.5201
List DOSE and FREQUENCY of ALL Medications, Supplements, Hormone Replacement, etc. which you
currently take: (including Aspirin)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Have you ever or are you currently experiencing any of the conditions listed below, circle Y or N:
Muscle or joint pain
Date
Y ___________ N
Numbness or Tingling
Y ___________ N
Swelling
Y ___________ N
Cancer
Y ___________ N
Sensitive to touch/pressure
Y ___________ N
High/Low Blood Pressure
Y ___________ N
Breath shortness/Asthma
Y ___________ N
Stroke/Heart Attack
Y ___________ N
Varicose Veins
Y ___________ N
Dizziness/Ear Ringing
Y ___________ N
Headaches/Migraines
Y ___________ N
Deep Bruises
Y ___________ N
Epilepsy/Seizures
Y ___________ N
Acid Reflux or GERD
Y ___________ N
Chest Pain
Y ___________ N
Soaking Sweats
Y ___________ N
Neurological Conditions-MS, Parkinson’s, etc
Y ___________ N
Kidney Disease/Infection
Y ___________ N
Bladder Disease/Infection
Y ___________ N
Degenerative Spine/Disk
Y ___________ N
Broken Bones
Y ___________ N
Depression/Anxiety
Y ___________ N
Osteoporosis
Y ___________ N
Scoliosis
Y ___________ N
Gigi Willett DMIc AATc LMT Manual Therapy
1780 South Bellaire Street Suite 303 Denver Colorado 80222
phone: 720.732.5201
Date
Endocrine/Thyroid Conditions
Y ___________ N
Memory Loss
Y ___________ N
Easily Overwhelmed/Confusion
Y ___________ N
Vomiting
Y ___________ N
Nausea
Y ___________ N
Clay/Chalky Stools
Y ___________ N
Black or Tarry Stools
Y ___________ N
Blood in Stools
Y ___________ N
Hemorrhoids
Y ___________ N
Digestive Conditions (IBS, Crohn’s, Celiac) Y ___________ N
Gas/Bloating/Constipation
Y ___________ N
Diarrhea
Y ___________ N
Trouble Swallowing
Y ___________ N
Vision Loss/Changes
Y ___________ N
Blood in Urine
Y ___________ N
Burning when urinate
Y ___________ N
Restless Leg Syndrome
Y ___________ N
Insomnia
Y ___________ N
PTSD/Trauma
Y ___________ N
Chronic Fatigue
Y ___________ N
Arthritis
Y ___________ N
Muscle or joint stiffness
Y ___________ N
Fibromyalgia
Y ___________ N
Multiple Chemical Sensitivities
Y ___________ N
Sleep Apnea
Y ___________ N
High Cholesterol
Y ___________ N
Blood Clots
Y ___________ N
Brain Injury or Concussion
Y ___________ N
Lyme Disease
Y ___________ N
Sweaty Hands/Feet
Y ___________ N
Gigi Willett DMIc AATc LMT Manual Therapy
1780 South Bellaire Street Suite 303 Denver Colorado 80222
phone: 720.732.5201
GENERAL:
Do you smoke cigarettes?
Y_ N_ #Per Day ___ How many years? _____
Have you ever smoked?
Y_ N _ When did you quit? _____
Do you drink alcohol?
Y_ N _ How many drinks per week?_____ Month_____
Do you wear contact lenses?
Y_ N _
Do you wear dentures?
Y_ N _
Do you wear a hairpiece?
Y_ N _
Do you have a pacemaker?
Y_ N _
Upper _ Lower _ Both _
Do you have any joint replacement hardware? Y_ N _ Describe if Yes _______________________
When was your last physical exam or health visit ?_______________
Known Allergies? Y_ N _ Describe _________________________________________________
Are you Pregnant? Y _ N _ How many Pregnancies? _______________________
Payment and Cancellation Policy:
• Payment for treatment is due at time of service. No insurance processing available.
• Full Fee charged for Missed Appointments and Cancellations with less than 24-hour notice.
Initials ________
Consent For Treatment:
I understand bodywork practitioners are not qualified to perform medical examination, diagnose, prescribe or treat
any physical or mental illness and that I should see a qualified physician for any mental or physical ailment of which
I am aware. If I experience any discomfort during my session I will immediately inform the practitioner. I agree to
keep the practitioner updated as to any changes in my health profile and affirm I have stated all my known medical
conditions and answered questions honestly. I agree and give consent to the manual therapy treatment given to my
by Gigi Willett, Manual Practitioner.
____________________________________________________________________________
Signature (or Guardian, relationship to client ____________________)
Date
Thank you! I look forward to working with you! Gigi Willett, DMIc AATc LMT Manual Therapy
Certified practitioner of
Lowen Systems Dynamic Manual Interface
Associate Awareness Technique
Gigi Willett DMIc AATc LMT Manual Therapy
1780 South Bellaire Street Suite 303 Denver Colorado 80222
phone: 720.732.5201