Sollievo Massage and Bodywork

Sollievo  |  2285 Massachusetts Ave  |  Cambridge, MA 02140
Book Your Appointment! Click Here or Call (617)354.3082

Moxa and Cupping Health History Form

First Name *
Last Name *
Address *
City *
State *
Zip *
Best phone number to reach you *
Email *
Date of Birth *
Do you wish to fill out the complete form now?
Yes No
Secondary phone number
Occupation:
Contact Person In Case of Emergency:
Full Name:
Phone:
Relationship:
Physician's Full Name:
Physician's Phone:
Medical Insurance Carrier:
Medical Insurance Carrier Phone:
Have you tried acupuncture or Chinese herbal medicine before?
Yes No
What is your main health concern?
Please check any of the following conditions you have experienced within the last three months. Indicate the length of time you have had any of these conditions.
General
Condition:
Comments:
Poor Appetite
Insomnia
Disturbed Sleep
Localized Weakness
Cravings
Strong Thirst
Poor Balance
Weight Gain
Weight Loss
Changes in Appetite
Excessive Sweating
Tremors
Bleed or Bruise Easily
Night Sweats
Fever
Chills
Sudden Energy Drop (Time of Day?)
Skin and Hair
Condition:
Comments:
Rashes
Ulcerations
Hives
Itching
Eczema
Pimples
Dandruff
Hair Loss
Recent Moles
Texture Change (Hair/Skin)
Head, Eyes, Ears, Nose, Throat
Condition:
Comments:
Dizziness
Eye Strain
Migraines
Ringing in Ears
Poor Hearing
Color Blindness
Facial Pain
Blurry Vision
Earaches
Sinus Problems
Recurrent Sore Throats
Nose Bleeds
Grinding Teeth
Jaw Clicks
Headaches (Where/When?)
Cardiovascular
Condition:
Comments:
Low Blood Pressure
Chest Pain
Irregular Heartbeat
High Blood Pressure
Fainting
Cold Hands or Feet
Swelling of Hands
Swelling of Feet
Blood Clots
Difficulty Breathing
Respiratory
Condition:
Comments:
Cough
Coughing Up Blood
Asthma
Bronchitis
Pain with Deep Inhalation
Pneumonia
Difficulty Breathing when Lying Down
Excessive Phlegm (Color?)
Gastrointestinal
Condition:
Comments:
Nausea
Vomiting
Diarrhea
Constipation
Indigestion
Hemorrhoids
Abdominal Pain or Cramps
Chronic Laxative Use
Genitourinary
Condition:
Comments:
Pain During Urination
Frequent Urination
Urgency to Urinate
Unable to Hold Urine
Kidney Stones

Yes No
How often?
Reproductive and Gynecologic
Condition:
Comments:
Premenstrual Changes
Menstrual Clots
Painful Menses
Unusual Menses
Heavy Menstrual Flow
Light Menstrual Flow
Irregular Menses
Musculoskeletal
Condition:
Comments:
Neck Pain
Muscle Pains
Knee Pain
Back Pain
Muscle Weakness
Foot/Ankle Pain
Hand/Wrist Pain
Shoulder Pain
Hip Pain
Neuropsychological
Condition:
Comments:
Seizures
Loss of Balance
Areas of Numbness
Poor Memory
Lack of Coordination
Concussion
Depression
Anxiety
Bad Temper
Easily Susceptible to Stress
Please explain any other problems you would like to discuss.
How did you hear about us?
Would you like to receive email notifications regarding new services, discounts, promotions and more?
Check all that apply.



Consent for Care: It is my choice to receive acupuncture . I am aware of the benefits and risks of acupuncture and give my consent for acupuncture. I acknowledge that acupuncture is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.
  I Agree.
What is three plus four?
(Anti-spam question)

"Sollievo is an oasis in the middle of the city. It's a great, quiet atmosphere, with no distraction – I couldn't hear a thing outside the treatment room. Every detail here is first class. Sollievo has brought to North Cambridge something truly unique in bodywork."
– RL, Cambridge area senior

Sollievo - Massage and Bodywork

2285 Massachusetts Ave Cambridge, MA 02140

Conveniently located near Porter, Davis & Harvard Square and across the river from Boston.

Phone: (617)354.3082
Fax: (617) 354.3085
Email: info@sollievo.org

Copyright © 2012. All rights reserved

Web Design by theWebProjects