1.Client Information

First name / Last name

Birthday

2. Pain Level Assessment, Please rate your pain or discomfort before and after this message session.(0 = No pain, 10 = Most severe)

Head / Headache Before Treatment (*0= No pain, 10 = Most severe )

Head / Headache After Treatment (*0= No pain, 10 = Most severe )

Jaw / Face Before Treatment (*0= No pain, 10 = Most severe )

Jaw / Face After Treatment (*0= No pain, 10 = Most severe )

Neck Before Treatment (*0= No pain, 10 = Most severe )

Neck After Treatment (*0= No pain, 10 = Most severe )

Shoulder Left-Right Before Treatment (*0= No pain, 10 = Most severe )

Shoulder Left-Right After Treatment (*0= No pain, 10 = Most severe )

Arm, Elbow, Wrist , Hand Left-Right Before Treatment (*0= No pain, 10 = Most severe )

Arm, Elbow, Wrist , Hand Left-Right After Treatment (*0= No pain, 10 = Most severe )

Upper Back, Lower Back Left-Right Before Treatment (*0= No pain, 10 = Most severe )

Upper Back, Lower Back Left-Right After Treatment (*0= No pain, 10 = Most severe )

Leg, Knee, Ankle, Foot Left-Right Before Treatment (*0= No pain, 10 = Most severe )

Leg, Knee, Ankle, Foot Left-Right After Treatment (*0= No pain, 10 = Most severe )