What is bothering you today? headache headache neck neck left trap left trap right trap right trap mid back mid back low back low back left hip left hip right hip right hip left leg left leg right leg right leg left foot left foot right foot right foot What is the pain level of your headache today?*(1 = mild pain, 10 = severe)12345678910What is the pain level of your neck today?*(1 = mild pain, 10 = severe)12345678910Which side?* the left side the right side the middle both sides What is the pain level of your left trap today?*(1 = mild pain, 10 = severe)12345678910What is the pain level of your right trap today?*(1 = mild pain, 10 = severe)12345678910What is the pain level of your mid back today?*(1 = mild pain, 10 = severe)12345678910Which side?* the left side the right side the middle both sides What is the pain level of your lower back today?*(1 = mild pain, 10 = severe)12345678910Where is your low back pain?* the left side the right side the middle both sides What is the pain level of your left hip today?*(1 = mild pain, 10 = severe)12345678910What is the pain level of your right hip today?*(1 = mild pain, 10 = severe)12345678910What is the pain level of your left leg today?*(1 = mild pain, 10 = severe)12345678910What is the pain level of your right leg today?*(1 = mild pain, 10 = severe)12345678910What is the pain level of your left foot today?*(1 = mild pain, 10 = severe)12345678910What is the pain level of your right foot today?*(1 = mild pain, 10 = severe)12345678910Would you like a therapeutic or relaxation massage?* therapeutic relaxation Which areas would you like the therapist to focus on?* JUST my problem areas Problem areas but still have time allotted for the rest of me Have you had any car accidents, surgeries, trauma or injuries since your last visit?* Yes No For females, are you pregnant? Yes No How many weeks?* Have you had a recent cancer or cardiac diagnosis?* Yes No Are you currently undergoing chemotherapy?* Yes No Do you have any skin allergies, rashes, or open wounds?* Yes No Would you like to add an Aromatherapy upgrade for $10? Yes No Which essential oil? Bergamot (Uplifting & Rejuvenating) Lavender (Calming & Clarifying) Peppermint (Stimulating & Decongesting) In the last week, have you had a fever, a dry or painful throat, headache with sore throat, diarrhea, body aches or cough OR in the last 14 days have you been asked to self-isolate or quarantine by a doctor or had close contact or cared for someone diagnosed with COVID-19?* Yes No When?* Are you currently awaiting Covid-19 test results?* Yes No PLEASE NOTE: For the safety of everyone in this office, we ask that you please discontinue this check-in process and refrain from entering the office until you receive a negative test result.Please read the disclaimer below and check the box to agree* I understand that COVID-19 is highly contagious and still present in the community where I am seeking massage therapy. I understand that COVID-19 is passed through close contact with others and that people without symptoms may be infectious. I understand that Dr. Mel Youngs, D.C., P.A. has taken every precaution to ensure my health and safety, but that risk of infection is still possible.* * By ticking the box above and entering your initials below, you verify your identity and that you agree to the noted disclaimer. I would like to continue maintenance massages (weekly or monthly) Tell me about the rub club! Select the first letter of your FIRST Name1st*SelectABCDEFGHIJKLMNOPQRSTUVWXYZSelect the first two letters of your LAST Name1st*SelectABCDEFGHIJKLMNOPQRSTUVWXYZ2nd*SelectABCDEFGHIJKLMNOPQRSTUVWXYZ