Gigi Willett DMIc AATc LMT Manual Therapy 1780 South Bellaire Street Suite 303 Denver Colorado 80222 phone: 720.732.5201 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 5 6 7 8 9 10 > Most
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Gigi Willett DMIc AATc LMT Manual Therapy 1780 South Bellaire Street Suite 303 Denver Colorado 80222 phone: 720.732.5201
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 5 6 7 8 9 10 > Most
Gigi Willett DMIc AATc LMT Manual Therapy 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: Date
Muscle or joint pain 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 _ Upper _ Lower _ Both _ Do you wear a hairpiece? Y_ N _ Do you have a pacemaker? Y_ N _ 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
