Name  __________________________________   
Address   ________________________________  
City/ State/ ZIP  ___________________________  
Birth Date  ______________SSN _____________  
Primary Health Care Provider ________________   
Emergency Contact_________________________  
Date ________________________________
Phone-Day  ___________________________
Phone-Eve  ___________________________
Occupation  ___________________________
Phone  _______________________________
Phone  _______________________________
Permission to consult with primary provider, if appropriate? Please initial if yes______Yes  ______No    
I understand that appointments cancelled with less than 24-hour notice will be billed at the full price.


I ask these questions to better tailor my massage to your needs and to protect the health and well-being of my clients.  Please answer them as best you are able.

What are your goals for health and how may I assist you in achieving your goals? 

Have you ever received a professional massage? ___Yes ___ No
What results do you want from your massage today? __________________________________________
Are you currently experiencing any of the following?  If yes, please explain.
Pain or Tenderness _____ Yes___ No_____________ Stiffness  ___Yes ___No____________________
Numbness or Tingling ____Yes ___No_____________ Swelling ___Yes ___No ____________________
What makes it better? __________________________ Worse?_________________________________
Please check the areas of your body that you give permission to receive massage.
____Back_____Legs ___Buttocks____Arms____Abdomen___Chest ___Neck___Head ___Face___Feet
Are you currently seeing a medical practitioner, including chiropractor, acupuncturist, DO, naturopath, etc., including psychotherapist or support group?  If yes, please explain. ___Yes___No_____
List stress reduction and exercise activities, with frequency.  ____________________________________
List medication, including aspirin and ibuprofen, taken today. ___________________________________

PREVIOUS HISTORY Include year and treatment received.

Surgeries    ___________________________________________________________________________
Accidents   ___________________________________________________________________________ ____________________________________________________________________________________