Please enable JavaScript in your browser to complete this form.Personal InformationName *FirstLastPhoneDate of birthHow did you hear about us: Telephone PhoneEmergency ContactTel.AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Tel. General & Medical Information:Occupation: Age: Male: Female: Physician:Have you ever experienced a professional massage or bodywork session? Yes: No:If ‘yes’ how recently? What kind of Massage/bodywork?What is your primary complaint today? When did you first experience this condition? What makes it worse? What makes it better? Have you sought other remedies to this condition YesNoIf yes, specify. ( ) Physician ( ) Chiropractor ( ) Physical Therapist ( ) Complementary medicine (Explain modality) Are you taking any medication list (include herbs and vitamins) and explain purpose: CheckboxesFirst ChoicebbSecond ChoiceThird ChoiceMultiple ChoiceFirst ChoiceSecond ChoiceThird ChoiceCheckbox ItemsFirst ItemSecond ItemThird ItemPlease list/explain any surgeries or major injuries that you have experienced over time: Please check all that apply to you:Stress ___ Diabetes ___ Frequent headaches ___ Arthritis ___ Wear Contact lenses ___ Wear Dentures ___ Hypertension ___ Arteriosclerosis ___ Varicose Veins ___ Phlebitis ___ Cancer ___ TMJ syndrome ___ Easy Bruising ___ Skin Rash ___ HIV/AIDS ___ Skin Sensitivity ___ Allergies ___ Inner Ear Problems ___ Mental Illness ___ Osteoporosis ___ Osteoarthritis ___ Rheumatoid Arthritis ___ Psoriasis ___ Multiple Sclerosis/Lupus ___Herniated Disc ___ Pregnancy ___ Hyper Thyroid ___Hypo Thyroid ___ Epileptic Seizures ___ Joint Swelling ___ Broken bones in the last two years ___ Auto accident or major injuries ___ Cardiac or circulatory problems ___ Back pain ___ Numbness ___ Stabbing pain ___ Sensitive to touch/pressure ___ Do you have any other medical condition not listed above? If please, explain below: 1. Draw today’s symptoms on the figures. Use the letters provide in the key to identify your symptoms. 2. Circle the area around each letter to represent the size and shape of each symptom.NameSubmit
