Date MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Cell Phone * (###) ### #### Cell Phone Carrier * This is required in order to receive appointment reminders. Email * Occupation Emergency Contact Emergency Contact Phone Number (###) ### #### Who referred you to us? Are you currently experiencing any discomfort? Yes No If yes, briefly explain below. What makes it better? What makes it worse? Are you currently under the care of a physician, chiropractor, or alternative medicine provider? Yes No If yes, what are you being treated for? Are you currently receiving any other body therapies? Yes No If yes, what for? What specific areas would you like for us to focus on? Are there any areas you do NOT like massaged? (i.e. feet, stomach, head, face) What do you hope to accomplish with this massage? (i.e. decrease muscle tension/soreness, increase flexibility, etc.) How frequently and for how long do you exercise and what do you do? Include sports, Pilates, yoga, gardening and/or other physical activities. Approximately how many hours of sleep do you receive each night? What is your sleeping position? What is your daily intake of water, caffeine and alcohol? Please select any of the following that apply to you in the past or currently: HEADACHES Does Not Apply Past Currently Both Asthma Does Not Apply Past Currently Both Cold Hands/Feet Does Not Apply Past Currently Both Swollen Ankles Does Not Apply Past Currently Both Sinus Conditions Does Not Apply Past Currently Both Frequent Colds Does Not Apply Past Currently Both Allergies Does Not Apply Past Currently Both Loss of Smell/Taste Does Not Apply Past Currently Both Skin Conditions Does Not Apply Past Currently Both Painful/Swollen Joints Does Not Apply Past Currently Both Auto-immune Disorder Does Not Apply Past Currently Both Cancer Does Not Apply Past Currently Both Varicose Veins Does Not Apply Past Currently Both Blood Clots/DVT Does Not Apply Past Currently Both Heart Problems Does Not Apply Past Currently Both Pacemaker Does Not Apply Past Currently Both High/Low Blood Pressure Does Not Apply Past Currently Both Diabetes Does Not Apply Past Currently Both Epilepsy or Seizures Does Not Apply Past Currently Both Fainting Spells Does Not Apply Past Currently Both Pins and Needles in Arms, Legs, Hands, or Feet Does Not Apply Past Currently Both Neurological Problems Does Not Apply Past Currently Both Spinal Problems Does Not Apply Past Currently Both Herniated/Bulging Discs Does Not Apply Past Currently Both Osteoarthritis Does Not Apply Past Currently Both Arthritis Does Not Apply Past Currently Both Anxiety Does Not Apply Past Currently Both Depression or Panic Does Not Apply Past Currently Both Sleep Disturbance Does Not Apply Past Currently Both Loss of Memory Does Not Apply Past Currently Both Whiplash Does Not Apply Past Currently Both Bruise Easily Does Not Apply Past Currently Both Constipation/Diarrhea Does Not Apply Past Currently Both Contact Lenses Does Not Apply Past Currently Both Dentures/Partials Does Not Apply Past Currently Both Hemorrhoids Does Not Apply Past Currently Both Artificial/Missing Limbs Does Not Apply Past Currently Both Muscular Tension Does Not Apply Past Currently Both Sciatica Does Not Apply Past Currently Both Breast Augmentation Does Not Apply Past Currently Both Further explanation of any condition, surgeries, or other relative health information: Informed Consent * By placing a check beside each of the below items and hitting Submit, you acknowledge that you have read, understand, and consent to each statement. I understand the treatment here is not a replacement for medical care. As such, the therapist/practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform any spinal manipulations (unless specified under his/her professional scope of practice) I understand that the treatment is not a substitute of medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health. I understand that payment is due at the time of treatment. I agree to give at least 24 hours notice of cancellation of appointment, otherwise will be expected to pay for session. Thank you!
