DISCLAIMER - Please note, we will provide keypad code via text to gain access to Kim's office as a security measure.

First Name*:

Last Name*:

Email*:

Mobile*:

Address:

City:

State:

Zip:

Occupation:

Employer:

Medication:

Physician:

Age:

Birth Date:

Referred By:

Primary Reason for Appointment

Please answer the following questions by checking the appropriate answer. Please explain any Yes answers below.

1. Have you had a professional massage before?YesNo
2. Have you ever had surgery?YesNo
3. Do you have any spinal problems?YesNo
4. Are you pregnant? Do you have an IUD?YesNo
5. Do you wear contact lenses or dentures?YesNo
6. Do you take any prescribed medications?YesNo
7. Do you have chronic back pain?YesNo
8. Do you have frequent headaches?YesNo
9. Are you constantly tired?YesNo
10. Do you have any heart problems?YesNo
11. Do you have high blood pressure?YesNo
12. Do you have varicose veins?YesNo
13. Do you have any blood clots?YesNo
14. Have you ever had cancer?YesNo
15. Do you have arthritis?YesNo
16. Have you ever suffered from an acute injury?YesNo
17. Do you have pain that radiates down your arms or legs?YesNo
18. Do you suffer from tension?YesNo
19. Do you have chronic diarrhea?YesNo
20. Do you have constipation?YesNo
21. Do you have allergies/aversion to dogs?YesNo

Please explain any Yes anwsers:

Do you have any other medical condition which I should be aware?

If so please specify:

I, , understand that the massage therapy given here is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. I also acknowledge that I must give a 24 hour notice of any cancellation to an appointment or I will be subject to a fee. I will be responsible for full service fee. If I do not pay for missed or late cancellations, I must pre-pay for all future appointments.

I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. As such the massage therapist prescribes neither medical treatment or pharmaceuticals, nor performs any spinal manipulations. It has been made very clear to me that this massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.

Because a massage therapist must be aware of existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on my physical health.

Name: Date: