Clinic Staff: Mary Biancalana, Board Certified Myofascial Trigger Point Therapist Lisa Campana, Board Certified Myofascial Trigger Point Therapist

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1 An Overview of Our Practice Model N Nagle Ave Suite #3 Second Floor Clinic Staff: Mary Biancalana, Board Certified Myofascial Trigger Point Therapist Lisa Campana, Board Certified Myofascial Trigger Point Therapist What is Myofascial Trigger Point Therapy? It is muscle specific, hands-on treatment modality with outcome based goals; some of which can be: 1. To eliminate your muscle problems 2. To reduce and eliminate pain 3. To improve and restore full pain free strength and range of motion and 4.To teach you self-care techniques you can do at home to help you get better faster and stay pain free. Is it massage therapy? You will not be getting a massage exactly. The highly skilled and trained practitioners in our clinic are referred to as Myofascial Trigger Point Therapists. (MTPT s). Trigger Point Therapy is an advanced technique that takes over 12 months of study beyond massage school. It is considered an advanced form of manual therapy, and all of our therapists have a State of Illinois Allied Health Care Provider, Massage Therapy License. We use many hands-on Trigger Point Elimination techniques to return muscles to the relaxed, stretched pain-free and fully functional state. We focus on specific muscles that can be causing your pain, and work to eliminate the dysfunction in these muscles. Do you take or bill my insurance? No, we do not bill any insurance. You will be provided a Superbill that you can use to submit a claim to your insurance to see whether or not they will reimburse you. Description of the Treatment: 1. First visit: The first usually is 1.5 hours. On your first visit, we will be doing a Myofascial Initial Evaluation and then will develop a treatment plan based on our findings, your personal goals as well as the recommendations of your healthcare provider. Remember, because you have pain in a certain area does not mean that is where we will be working. Our model is based on the concept of referred pain. That is, a pain, numbness, tingling sensation is most likely coming from a trigger point in a far away muscle. This is a dynamic, movement-focused treatment with lots of communication between client and practitioner. You will be actively engaged in this treatment process. 2. Subsequent visits: are 50 minutes. Our treatment plans usually suggest 4-6 treatments to allow the modality to work in retraining dysfunctional and painful muscles. Over time these painful areas will be getting less painful, and your daily function will be increasing. 3. Exercise/Movement/ Self-care classes: Part of our complete practice model is to have our clients actively engaged in their rehabilitation. We encourage enrollment in our stretch and fitness classes to allow muscles to fully lengthen and strengthen while affording greater mobility and confidence.

2 Chicago Center for Myofascial Pain Relief Myofascial Trigger Point Therapy Symptom Chart Name: Date: / / * Please indicate on the drawing below where your pain is today with corresponding pain numbers. Use lines pointing to specific regions to separate pain levels and sensations in different areas and number accordingly. Feel free to add any descriptive words specific to any region. For example, your shoulder blades could be an 8/10 and burning while your front of shoulders are 3/10 and nagging. R L 2. Please place an X in the table below at a point that best corresponds to the general intensity of your overall pain No Moderate Excruciating Pain Pain Pain 3. Please place an X in the table below at a point that best corresponds to the general degree of dysfunction due to your pain No Moderate Complete Dysfunction Dysfunction Dysfunction 6304 N. Nagle Ave. Suite 3 Chicago, IL

3 Patient History Today s Date Please complete this form before your Initial Myofascial Trigger Point Therapy Evaluation and bring it with you to your appointment. Thank you. Patient Name: DOB: Address: City State Primary Phone: Secondary Phone: How did you hear about us? Emergency Contact Name: Phone _ Relation to Patient: Medical History How long have you had this muscular pain (and /or Fibromyalgia)? When did you notice the symptoms? Was there an event or illness that started the pain? Please list any accidents (e.g. car, bicycle, falls, impact injury ) or surgeries you have undergone, starting with the most recent: Date of accident/surgery Describe Accident/Surgery P a g e 1 6

4 Have you been told by a physician or Health care provider that you have any of the following: Herniated or Bulging Disks Yes / No Abdominal Hernia Yes / No Diabetes Yes / No Inguinal Hernia Yes / No Spinal Stenosis Yes / No Short Leg Yes / No Which one Scoliosis Yes / No Psoriasis Yes / No Thyroid problems Yes / No Rheumatoid Arthritis Yes / No Have you had any of the following: MRI, X-Rays, CAT Scan, EKG, Other Type of Scan / Test Date Performed Findings Do you currently wear shoe orthotics? Yes / No If yes, how long have you been wearing them? Do you now, or did you as a child, prefer to sit on one leg? Yes / No Do you prefer to stand on one leg? Yes / No If yes, which one? Do you have any food sensitivities? Yes / No If yes, please list: Are you currently or have you been vegan / vegetarian / lacto/ovo/vege Out of 14 days how many days would you eat beef: chicken fish eggs bison turkey lunch meats Please circle other therapists you are currently seeing or have seen in the past: Chiropractic (Now / Past) PT (Now / Past) Tens Unit (Now / Past) Acupuncture (Now / Past) Massage (Now / Past) Other: List any medications you are currently taking and it s indication (reason) ie: blood pressure, pain List any medications you have tried in the past and the reason you stopped taking it: P a g e 2 6

5 Personal Wellness What are your goals to improve the quality of your life? Pain Patterns / Body Chart Refer to the body chart below. Shade in the area(s) where you are experiencing pain. You can draw lines and provide specific pain levels in each area, or add any descriptive words to specify what you are feeling in that region, e.g., burning, sharp, shooting, dull, aching, numbness, tingling. Right Side R L L R Left Side Does anything INCREASE your pain? If yes, please explain. Does anything RELIEVE your pain? e.g., medication, heat, cold? Is the pain associated with any specific movements you make? Do you experience pain first thing upon waking up in the morning? If so, please describe. Does the level of pain increase, decrease, or stay the same in the evening before bed? P a g e 3 6

6 Women: At certain times of the month/week does your pain change? If so, how? Does your pain change with the weather? Yes / No How? Work Stress Are you able to work? Yes / No If yes, what is your occupation? Is your pain affecting you at work? If so, please describe. Do you perform repetitive movements at work? Yes / No Are you sitting at a desk for long periods? Yes / No Could you incorporate a standing desk in your workplace? Yes / No / Maybe How do you feel after a day of work? Home Stress Do you have childcare or home-tasks? Yes / No Are you immobile (resting or sitting) for long periods in your home? Yes / No Do you read while laying on a couch/bed? Yes / No Exercise Are you able to exercise? Yes / No IF YES, what type of exercises do you do and how frequently? Please be specific. IF NO, what are your reasons for not exercising? What kind of exercises do you think you would enjoy doing if you could? Stress How stressed are you from day to day (please circle)? High High-Medium Medium Medium-Low Low Are you a quiet worrier (keeping worry and thoughts inside?) Yes / No Do you sometimes wake up due to your mind racing or thinking about stuff? Yes / No Do you catch yourself holding your breath when you are concentrating? Yes / No Have you been unable to get a full breath, or stuck below a full yawn? Yes / No P a g e 4 6

7 Sleep What position do you most often sleep in? (circle all that apply and give a percentage per night) Back Side Stomach Arms Overhead Arms under pillow ( under head) Half-stomach/half side Fetal position Pets in bed Spooning with partner If you sleep on your back: Do you use pillows under the knees? Yes / No Has a partner/ spouse told you that you snore? Yes / No Have you even had a sleep study? Yes / No If you sleep on your side: Do you use any pillows between the legs? Yes / No Do you use any pillows at the chest? Yes / No How often do you sleep in each position? Does your partner (or pets) wake u up when sleeping? Yes / No How often per week Are there any reasons you sleep in these positions? How many hours of sleep do you typically get? Do you have difficulty falling asleep? Yes / No Do you wake up often in the middle of your sleep? Yes / No How many times: Do you wake up to urinate? Yes / No How many times per night? per week? Do you wake up feeling tired? Yes / no How many days per week do you wake tired? Smoking/Alcohol/Caffeine/Sugar Do you smoke or use tobacco products? Yes / No If yes, what kind and how much per day? Do you drink alcohol? Yes / No If yes, what kind and how often? Do you drink caffeinated beverages? Yes / No If yes, what kind and how often or how many cups or cans or servings? Do you drink juice? Yes / No If yes, what kind and how often? Are you drawn to eating: sweets / candy / cake / ice cream / cookies / salty chips Do you frequently eat food with high amounts of sugar/carbohydrates? Yes / No P a g e 5 6

8 If yes, what kind and how often? Water/Supplements How much water do you drink a day? (eg; 1 cup, 1 bottle, 1 glass) Please list any vitamins, minerals, or supplements you are currently taking: Jaw/Facial Pain Do you have TMJD? Yes / No Do you have jaw pain associated with chewing or yawning? Yes / No Do you wear a night guard or mouth splint? Yes/No Do you clench or grind your teeth? Yes / No When was your last dental appointment? When was your last eye exam? Do you wear bifocals/trifocals? HIPPA AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION (If needed) I, hereby authorize Muscle Health LLC. Dba Chicago Center for Myofascial Pain Relief to discuss my treatment and disclose my massage therapy records to the following health providers: Name Phone: Name Phone: Name Phone: Name Phone: I understand that I may revoke this authorization at any time, but that I may not hold Muscle Health LLC. Dba responsible for acting in a reasonable reliance on this statement prior to the time that it learns of my revocation. I understand that this authorization expires one year after the date signed below, unless I inform Muscle Health LLC. Dba otherwise. Signature of Client (or legal representative, state relationship) Today s Date: Thank you for taking the time to complete this form. We look forward to working with you on your journey toward better health! P a g e 6 6