* First Name
* Last Name
* Address Street 1
* Address Street 2
* Address City
* Address State
Any State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
* Address Postal Code
* Email
* Phone Number*
* Birthday
Month
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Day
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1922
* Occupation
* Emergency Contact Name
* Emergency Contact Phone*
* Date of Initial Visit
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2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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2003
2002
2001
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1998
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1996
1995
1994
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1992
1991
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1982
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1955
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1952
1951
1950
1949
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1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
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1923
1922
* 1. Have you had a professional massage before?
No
Yes
* If yes, how often do you receive massage therapy?
* 2. Do you have any difficulty lying on your front, back, or side?
No
Yes
* 3. Do you have any allergies to oils, lotions, or ointments?
No
Yes
* 4. Do you have sensitive skin?
No
Yes
* 5. Are you wearing any of the following? (select all that apply)
Contact lenses
Dentures
Hearing aid
* 6. Do you sit for long hours at a workstation, computer, or driving?
No
Yes
* 7. Do you perform any repetitive movement in your work, sports or hobby?
No
Yes
* 8. Do you experience stress in your work, family, or other aspect of your life?
No
Yes
* If yes, how do you think it has affected your health?
* 9. Any particular area of the body where you're experiencing tension, stiffness, pain or discomfort?
Yes
No
* Do you have any particular goals in mind for this massage session?
* 10. Are you currently under medical supervision?
No
Yes
* 11. Do you see a chiropractor?
No
Yes
* If yes, how often?
* 12. Are you currently taking any medication?
No
Yes
* If yes, please list or provide a list of medications to keep on file if it is extensive.
* Please check any condition listed below that applies to you
allergies/sensitivity
artificial joint
atherosclerosis
back/neck problems
cancer *
carpal tunnel syndrome
circulatory disorder
contagious skin condition
current fever
decreased sensation
deep vein thrombosis/blood clots
diabetes
distal neuropathy
easy bruising
edema
epilepsy
Fibromyalgia
headaches/migraines
heart condition
Herpes or cold sores
high or low blood pressure
HIV/AIDS
joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis
open sores or wounds
osteoporosis
phlebitis
pregnancy
recent accident or injury
recent fracture
recent surgery
recently delivered child or had cesarean
sprains/strains
swollen glands
tennis elbow
TMJ
varicose veins
N/A
* If you marked cancer, please explain: Type of cancer
* Date diagnosed
* Are you currently being treated?
* When was your last treatment?
* Are you under the care of an oncologist?
* Name of oncologist if so
* If you are pregnant, how far along are you? **
* If you recently had a child, how long ago did you deliver/have a cesarean? ***
* Have you recently had any surgical procedures?
No
Yes
* If yes, please list procedure and date
* Are you currently still seeing a medical professional for the aforementioned procedure? ****
No
Yes
* Please explain anywhere yes was chosen (please number answers to match the question number)
* Is there anything else in your health history for your massage practitioner to know?
* Signature of Client