Patient Intake Form

Personal Information
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Massage Experience
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Current Health
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Health History
Bone or Joint Disease Tendonitis/Bursitis Arthritis/Gout
Jaw Pain (TMJ) Lupus Spinal Problems
Migraines/Headaches Osteoporosis
Heart Condition Phlebitis/Varicose Veins Blood Clots
High/Low Blood Pressure Lymphedema Thrombosis/Embolism
Breathing Difficulty/Asthma Emphysema Sinus Problems
Shingles Numbness/Tingling Pinched Nerve Chronic Pain Paralysis Multiple Sclerosis Parkinson's Disease
Ovarian/Menstrual Problems Prostate Pregnant
Rashes Cosmetic Surgery Athlete's Foot Herpes/Cold Sores Allergies
Irritable Bowel Syndrome Bladder/Kidney Ailment Colitis Crohn's Disease Ulcers
Anxiety/Stress Syndrome Depression
Cancer/Tumors Diabetes Drug/Alcohol/Tobacco Use Contact Lenses Dentures Hearing Aids
I agree that the above information is correct and accurate

Hours: M-F 8 am - 7 pm

Sat by appointment only

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