Name Phone (day) Phone (evening) Address City/State/Zip DOB Occupation Employer Email Primary Physician Emegency Contact Relationship Phone Relationship How did you hear about us? Medical InformationAre you taking any medications? YesNoIf yes, please list name and use Are you currently pregnant? YesNoIf yes, how far along? Any high risk factors? Do you suffer from chronic pain? YesNoIf yes, please explain What makes it better? What makes it worse? Have you had any orthopedic injuries? YesNoIf yes, please 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: Massage InformationHave you had a professional massage before? YesNoWhat type of massage are you seeking? RelaxationTherapeutic/Deep TissueOther What 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?