Patient Forms Please fill out the Client Health form below! REQUIRED FOR ALL NEW PATIENTS. Please answer every question. If you don’t have an answer, write N/A. Health Intake Form(required for all clients) Conversational Form (#5)Health Intake FormYour NameEmail Phone AddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweMassage History/Treatment Information List your past massage sessions and/or experiences.Primary Care Provider (if any)Have you ever had a professional massage?What results do you want from your sessions? May we consult with your primary care provider?- Select -YesNoAre you currently seeing a healthcare practicioner?- Select -YesNo Are you currently seeing a Counselor, Psychotherapist, or a Support Group?- Select -YesNoPlease tell us of any areas of your body where you would prefer to NOT receive a massage:Prioritize some areas of your body that you prefer to be massagedList Stress Reduction and Exercise Activities. Please include frequency:List current Medications, Herbals & Supplements and reason for use. Health HistoryCirculatory Heart Condition Varicose Veins / Phlebitis Blood Clots High / Low Blood Pressure Lymphedema Thrombus / EmbolismMusculoskeletal Bone & Joint Disease Tendonitis / Bursitis Broken / Fractured Bones Arthritis / Gout Jaw Pain / TMD Lupus Sprains / Strains Low Back, Hip, Leg Pain Neck, Shoulder, Arm Pain Headaches, Head Injuries Spasms / CrampsRespiratory Breathing Difficulty / Asthma Emphysema Sinus ProblemsReproductive Ovarian / Menstrual Problems Prostate PMSNervous Herpes / Shingles Numbness / Tingling Pinched NerveSkin Rashes Athletes Foot Herpes / Cold SoresDigestive Constipation Gas / Bloating DiverticulitisOther Health Issues Cancer / Tumors Diabetes Chronic Fatigue Chronic Pain Eating Disorders Sleep Disorders Bladder / Kidney Ailment Drug / Alcohol Addiction Caffeine / Tobacco Addiction Migraines / Headaches Anxiety / Stress Syndrome Depression Contact LensesAny Surgeries: Previous History (Past 12 Months)Any Accidents: Previous History (Past 12 Months) I have read and agree to the Terms for - Massage Policies and Guidelines and the Terms for - Consent and Contract for Care.Submit
