Name
*
First Name
Last Name
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Company Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact Name and Phone Number
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How did you hear of Living True?
What is your goal for this session?
If you have ever had a professional massage, when was the last time?
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Month
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Day
Year
Date
If you are experiencing pain today, please describe what it feels like (sharp, dull, numbness, tingling)
Circle areas you would like massage, and mark with an "X" any places to be avoided:
Medical History
Please list any conditions you currently have (ex: TMJ, hypertension, Carpal Tunnel Syndrome, etc.)
Please list any serious injuries you have endured
Do you suffer from chronic or persistent pain or discomfort? If so, do you know what caused the pain initially?
What makes the pain better or worse?
Do you see any other healthcare practitioners? (ex: chiropractors, acupuncturists). If so, indicate how often and when did you begin?
Please list any medications you are on and what they are taken for
Personal History
What is your occupation?
What type of exercise do you do, and how often?
Is there anything else you would like me to know?
Please verify that you are human
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I understand that the health session I receive with a Living True practitioner is for therapeutic and/or relaxing purpose. I will communicate to my therapist at any time if I feel uncomfortable or I am in pain.
*
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