Please enable JavaScript in your browser to complete this form.First NameLast NameSexFemailMailMarital StatusChildrenWhat are your Hobbies and activities?Date of birthOccupationEmail *Mobile Phone #Home Phone #Work Phone #Street AddressCityStateZip CodeEmergency contact namePhysician’s nameEmergency contact relationshipPhysician’s phone #Emergency phone #Date of initial visitHow would you rate your general health?ExcellentGoodFairPoorHave you had a professional massage before?YesNoList current medications & the conditions they are treatingList any major accidents or surgeries (including dates)Please tell us about any allergies or hypersensitivitiesReason for initial visitHEAD NECKHeadaches / migrainesVertigo / dizzinessRinging in earsHearing lossVision problemsVision lossNERVOUS SYSTEMSensory loss / changeNumbness / tinglingSciaticaEpilepsySeizuresMultiple sclerosisCARDIOVASCULARHigh blood pressureHeart attackLow blood pressureStrokeHeart diseasePoor circulationPhlebitis / varicose veinsPacemakerHemophiliaChronic congestive heart failureFamily history of cardiovascular problemsRESPIRATORYAsthmaShortness of breathChronic coughBronchitisEmphysemaSinusitisFrequent coldsSmokerFamily history of respiratory difficultiesSKIN & INFECTIONSHepatitisHIV / AIDSHerpesTuberculosisLyme diseaseInfectious skin conditionsREPRODUCTIVEPregnantGiven birthGynecological problemsOTHER CONDITIONSCancerDiabetesUnexplained weight lossDigestive conditionsFibromyalgiaChronic fatigue syndromeDepressionAnxietyPsychiatric disorderOther conditionsMUSCULOSKELETAL SYSTEMArthritisFamily history of arthritisOsteoporosisTendonitisBursitisJaw pain (TMJ)Pins / plates / wires / artificial jointOther ConditionSignatureIt is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.DateWebsiteSubmit
