Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 3Personal Information Personal InformationName *Phone *LayoutAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *LayoutOccupation *Employer *Email *Primary Physician *LayoutEmergency Contact *Relationship *Phone *How did you hear about us? *NextMedical Information Are you taking any medications? *YesNoPlease list name and use:Are you currently pregnant? *YesNoHow far along?Any high risk factors?Do you suffer from chronic pain? *YesNoPlease explain:What makes it better?What makes it worse?Have you had any orthopedic injuries? *YesNoPlease list:Please indicate any of the following that apply to you.CancerHeadaches/MigrainesArthritisDiabetesJoint Replacement(s)High/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or StrainsExplain any conditions you have marked above:NextMassage Information Have you had a professional massage before? *YesNoWhat type of massage are you seeking? *RelaxationTherapeutic/Deep TissueWhat pressure do you prefer *LightMediumDeepDo you have any allergies or sensitivities? *YesNoPlease explain:Are there any areas (feet, face abdomen, etc.) you do not want massaged? *YesNoPlease explain:What are your goals for this treatment session? *List any areas of discomfort, if any:Signature * Clear Signature By signing this form, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the information on this form changes at any time.Submit
