Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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Occupation
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
Emergency Contact Phone Number
*
-
Area Code
Phone Number
If under a physicians care, please explain below
If yes, who is your healthcare provider and what is their contact information?
Have you ever received a massage before? If so, when?
How did you hear about me?
Please list any recent injuries or surgeries within the last 5 years:
Health Information | Please select ALL current conditions| List ALL past conditions in bottom other box
Abdominal/Digestive Issues
Allergies
Anxiety
Arthritis/Tendonitis
Asthma or Lung Related Issues
Athletes Foot
Blood Clots
Chronic Pain
Circulatory Problems
Constipation/Diarrhea
Depression
Diabetes
Fatigue
Headaches or Migraines
Hearing Problems
Hernia
High Blood Pressure
Jaw Pain/TMJ
Low Blood Pressure
Muscle/Bone Injuries
Muscle/Joint Pain
Numbness/Tingling
Pregnancy
Rash/Fungus
Sinus Problems
Sleep Difficulties
Spinal Disorder
Sprain/Strain
Tension/Stress
Vision Problems
Varicose Veins
Other
Elaborate on noted areas above:
Please list your stress-reduction activities, hobbies, exercise and/or sport participation
Please list areas of tension, stress and/or pain you wish to be addressed:
What are your goals for this session?
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