Questionnaire

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Flu or Cold Inflammation Fever Infection Contagious Disease
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Fibromyalgia Spasms/Cramps Sprains/Strains Osteoporosis Postural Deviations Gout Osteoarthritisaheumatoid Arthritis TMJ Cysts Bursitis Plantar Fascitis Tendonitis Torticollis Whiplash Syndrome Carpal Tunnel Syndrome Sciatica Thoracic Outlet Syndrome Headache Leg Pain Arm Pain/shoulder Pain Low Back Pain Mid Back Pain Hip Pain Other
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Pneumonia Sinusitis Asthma Trouble Breathing Dizziness Other
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Anemia Hemophilia Hypertension Low Blood Pressure Raynaud's Disease Varicose Veins Heart Condition Blood Clots/phlebitis Diabetes Other
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Ulcers Irritable Bowel Syndrome Colitis Gallstones Hepatitis Crohn's Disease Diarrhea Gas/bloating Indigestion Other
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Fungal Infections Acne Impetigo Dermatitis/eczema Psoriasis Open Wound Or Sore Rashes Warts/moles Athletes Foot Other
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ALS Multiple Sclerosis Parkinson's Disease Bell's Palsy Neuritis Spinal Cord Injury Stroke Trigeminal Neuralgia Seizure Disorders Numbness/tingling/twitching Other
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Insomnia Anxiety/panic Attacks PMS Grief Process Cancer Substance Abuse Pregnancy Chronic Fatigue Hiv/aids Lupus Kidney Disease Bladder Infection Postoperative Situation Edema Other
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Before your Appointment



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    • If you answers “yes” to any of the questions above, I will need to reschedule your appointment until your symptoms (cough, fever and shortness of breath) have been resolved, for at least 14 days after and if you think you had contact with a person sick with cough, fever, or diagnosed COVID-19.
    • We reserve the right to cancel upon your arrival if necessary.
    • The door will remain closed just text or leave a message when you are outside. I will contact you when ready for your appointment.
    • We are following all recommended OSHA, AMTA and CDC guidelines, we ask that you wear a mask during your visit ( if you do not have one there will be some available for you at 1.50 each)
    • Please do not make your appointment right after exercising.
    • Review and fill out forms on line before your appointment.
    • Only the person with the appointment will be allowed in, except special need clients.


Covid-19 Liability Waiver



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Milagros Altamirano LMT 1211

Massage Cranial Release Therapy Center