Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Phone

(###)

###

####

Check any current or past head and neck problems

Headache/Migraine

Vision problem

Vertigo

Hearing loss

Check any current or past respiratory problems

Asthma

Chronic cough

Emphysema

Frequent colds

Shortness of breath

Bronchitis

Smoker

Check any current or past nervous system problems

Sciatica

Seizures

Numbness/tingling

Epilepsy

Multiple Sclerosis

Check any current or past musculoskeletal problems

Arthritis

Osteoporosis

Bursitis

Artificial joints/pins/plates

Tendonitis

TMJ/Jaw Pain

Check any current or past reproductive history

Pregnant

Gynecological issues

Given birth

n/a

Check any current or past cardiovascular problems

High blood pressure

Heart attack

Heart disease

Phlebitis

Hemophilia

Congestive heart failure

Low blood pressure

Stroke

Poor circulation

Pacemaker

n/a

Check any current or past skin infection problems

Hepatitis

Herpes

Lyme Disease

HIV

Tuberculosis

Infectious skin diseases

Check any current or past other health issues or concerns

Cancer

Fibromyalgia

Depression

Chronic Fatigue Syndrome

Digestive conditions

Anxiety

Consent For Massage *

It is my choice to receive massage therapy. I am aware of the benefits and risks and give my consent for massage. I have stated all my medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that all information provided and discussed will be kept confidential unless required by law.