Massage Check In

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)

What is the pain level of your neck today?*

(1 = mild pain, 10 = severe)

Which 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)

What is the pain level of your right trap today?*

(1 = mild pain, 10 = severe)

What is the pain level of your mid back today?*

(1 = mild pain, 10 = severe)

Which 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)

Where 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)

What is the pain level of your right hip today?*

(1 = mild pain, 10 = severe)

What is the pain level of your left leg today?*

(1 = mild pain, 10 = severe)

What is the pain level of your right leg today?*

(1 = mild pain, 10 = severe)

What is the pain level of your left foot today?*

(1 = mild pain, 10 = severe)

What is the pain level of your right foot today?*

(1 = mild pain, 10 = severe)

Would 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?*

Have you been to our office since we reopened in April?*

Yes
No

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 Name

1st*

Select the first two letters of your LAST Name

1st*

2nd*