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Client Information
First name
*
Last name
*
Birthday
*
Month
Day
Year
Area Code/Phone
*
Email
*
Confirm Email
*
Occupation
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone
*
Medical Information
Are you taking any medications?
*
Yes
No
If yes, please list name and use:
Are you currently pregnant?
*
Yes
No
*DISCLAIMER: I am
not
accepting pregnant clients at this time.
Any high risk factors?
*
Yes
No
If yes, please explain:
Do you suffer from chronic pain?
*
Yes
No
If yes, please explain:
What makes the chronic pain better?
What makes the chronic pain worse?
Have you had any orthopedic injuries?
*
Yes
No
If yes, please list:
Please indicate any of the following that apply to you:
*
Not Applicable (N/A)
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement
High/Low Blood Pressure
Neurotherapy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
Blood Thinners
Recent Surgery
If you've undergone recent surgery, what kind of surgery?
Explain any conditions you have marked above:
Are there any other conditions that are not listed above?
Have you had a professional massage before?
Yes
No
What pressure do you prefer?
*
Light
Medium
Do you have any allergies or sensitivities?
*
Yes
No
If yes, please explain:
What are your goals for this treatment session?
*
Signature
*
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Date
*
Month
Day
Year
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