Client Application Form

Client Application Form
Welcome and thank you for your interest!

Please note that though I am a Licensed Massage Therapist of over 12 years I do not perform Swedish, relaxation, or full body massage services. Due to the specialization of my training in complicated orthopedic conditions this application process is in place to identify individuals most in need of specialized assessment and treatment. This does not mean you cannot apply or that massage therapy in general won't help you, but I am limited in how many clients I can service at a time. If you complete the application I will respond to you with subsequent recommendations. Thank you in advance for your understanding.
Please indicate the category(ies) you identify with below. If none of these characterize your situation then I may recommend you to seek another practitioner.*

Acute injury due to athleticsCompetitive athlete focused on preventing injurySeeking reduction of dysfunctional patterns (posture, stress) that lead to chronic painReferred by health professional for specific treatment
Referred by (if applicable):
Name*

First NameLast Name
Cell phone number*
Used for reminders and communication but never spam!
Email *
For appointment confirmation and reminders. We will not sell or spam your account.
Birthdate

MonthDayYear
Emergency Contact Phone Number
Only used in medical emergencies.
What is your primary concern and can you identify possible causes?*
Please indicate all previous treatments tried for this injury.

massage therapychiropractorphysical therapyorthopedic consult/ images takenOther
Please describe in your own words your level of stress on the body, both physical and emotional. What do you believe has the greatest impact on these levels (ie, poor sleep, tightness or physical limitations, disassociation from sensations in the body, nutrition, work habits, etc)?
Everything affects everything in the body! Treating symptoms does not lead to pain free living.
Briefly list any surgeries or major injuries (Scar tissue can influence movement in a multitude of ways).
Habits
How many days a week do you exercise for 30 min or more?

Never1-3 days5-7 days
How many hours a day are you seated at a desk, in the car, or on the couch? An estimated bare minimum is 2 hours a day.

2-5 hours5-9 hours11 hours or more (1+ hrs driving, 8+ hrs workday, 2+ hrs on couch)
What is your 'work day average' number of hours of sleep you get?*

less than 6 hrs6-9 hrs9-12 hrs
Do you follow a diet plan?

I don't follow a diet planI have a loose dietI have a strict diet
How much plain water do you consume regularly?

0-8 oz/day16-24oz/day32+oz/day
How much caffeine do you consume regularly?

I don't use caffeine1-2 cups/day3-4 cups/day
How much alcohol do you consume regularly?

I don't drink or drink only a few times a year1-3 drinks a week1-3 drinks a day
The preceding habits can seriously impact your body's ability to HEAL and function. Pain relieving drugs, whether prescribed or not can also affect the pain perception and regulatory systems in the body. If you would like to discuss these areas of health please indicate yes.
What is your general availability for an appointment in the next month? I will email specific dates to you after reviewing your information.*

weekdays 8:30am-1pmweekdays after 4pmSunday after 3pmI have a rotating schedule
Should be Empty:

Client Application Form

Welcome and thank you for your interest!

Habits