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Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: ____________________ Health Status Update
Contact Information: ________________________
Client Information
Client Name: ______________________________ Date: ____________________ Date of Birth: _______________
Depict how you are feeling today by drawing a circle on the figures representing the size and shape of the
following symptoms. Place the letter representing the symptoms in or near the circle:
Rate how you are feeling today by drawing a circle around the number that best represents how you are doing today:
No pain 0 1 2 3 4 5 6 7 8 9 10 Worst pain imaginable
Able to do everything 0 1 2 3 4 5 6 7 8 9 10 Not able to do anything
Comments
Is there anything else I should know about how you are feeling today or about your progress or care to date?
Signature: _________________________________________ Date: _________________
P = Pain, ache, or tenderness
S = Stiffness in the joint or muscle
L
L
R
R
click to sign
signature
click to edit
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