Consultation Form
Obed therapy
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
For the following, put N/A for anything that does not apply to you.
How did you hear about Obed therapy?
List any medications you currently take:
*
Please list allergies or sensitivities:
*
Please list any injuries or surgeries in the last two years
*
Preferred Massage Pressure?
*
Light, medium or firm.
Please check all that apply.
*
Pregnant
Postpartum
Neck Pain
Back Pain
Headaches
High Blood Pressure
Bruise Easily
Diabetes
Seizures
Knee/Leg Pain
Jaw Pain / Clenching/ Grinding
Metal Implants
Fibromyalgia
Used Retin -A within the past 10 days?
Cancer/tumour
Autoimmune disorder
Low blood pressure/hypotension
High blood pressure/hypertension
Cardiovascular/respiratory illness
Neuropathy
Unremitting night pain
Other
What is your goal for this session?
*
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: