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 *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *Occupation *EmployerName of Primary Care Physician *PhonePermission to Consult with Primary Care Physician? *YesNoEmergency Contact Name *Phone *Who referred you to my office?Prenatal Health InformationObstetrician/Midwife *PhoneBirthing Facility/Location *Permission to consult with Obstetrician or Midwife? *YesNoHow many weeks pregnant are you? *Estimated Due Date *How has this pregnancy been for you? Any complaints? *Number of Pregnancies *Number of Births *Do you work at a job that requires sitting for long periods of time? *YesNoHave you taken birth control pills in the past year before becoming pregnant? *YesNoAre you experiencing any of the following conditions: *DiabetesFeverHeadachesHigh blood pressureNauseaPre-eclampsia or toxemiaProblems with circulationSwellingThrombophlebitisVaricose veinsOtherNone of the abovePlease explain any of the conditions you selected: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. * Clear Signature SignatureEmailSubmit Share this: Print (Opens in new window) Print Email a link to a friend (Opens in new window) Email Share on Facebook (Opens in new window) Facebook Share on LinkedIn (Opens in new window) LinkedIn
