Please enable JavaScript in your browser to complete this form.Personal InformationName *FirstLastEmail *Cell Phone *Home PhoneWork PhoneAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *Occupation *EmployerName of Primary Care Physician *PhonePermission to Consult with Primary Care Physician? *YesNoEmergency Contact Name *Phone *Who referred you to my office?Health HistoryDescribe reason for this visit: *When did you first notice symptoms? *What brought it on? *What activities aggravate the condition? *What activities or products improve the condition? *What have you done to get relief? *Are you currently seeing a medical practitioner for any reason? *YesNoIf yes, please explain.Please list any prescription or over-the-counter medications you are currently taking. (Include reason for taking them) *Describe any current or past major injuries, surgeries, or traumas. (Include year and treatment received) *Describe any current or past major illnesses or medical conditions. *Do you have any skin conditions or allergies? *YesNoIf yes, please explain.Do you wear contact lenses? *YesNoAre you pregnant or trying to become pregnant? *YesNoN/AHave you ever had massage before? *YesNoIf yes, what did you especially like or dislike?Where do you tend to hold stress in your body?Please describe your stress reduction and exercise activities. Include frequency. *Informed ConsentIt is my choice to receive massage therapy. I understand that the treatment is being given for the well being of my body and mind. This includes, but is not limited to: stress reduction, relief from muscular tension, spasm or pain, increased range of motion, and for increasing circulation. I agree to communicate with my practitioner any time I feel like my well being is being compromised. I understand that massage therapists do not diagnose illness, disease, or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service. I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes. SignatureI understand and agree to the terms outlined in the Informed Consent above. By typing my name above, I acknowledge that this serves as my electronic signature, and I consent to the terms stated herein.Submit