About you

Todays Date _____/______/______

Patient Name: ___________________________________ What you prefer to be called ________________
LAST

FIRST

MI

Birth date: ______/______/_____

Age: ________
Mailing Address:____________________________________________

Male

Female

___________________________________________________________
City

State

Zip

Home Phone #: ______________________Work Phone #: ____________________ Ext: _________

Other Phone #: _____________________________
Email: ____________________________________
What is your occupation? _________________________________
How did you hear about us? _______________________________
Have you been treated by a Massage Therapist before? Yes No
If so, who? _________________________________________
What kinds of pressure do you prefer?

Light

Medium Firm

Do you have a Facebook page? ___Yes ___No

Can we send you a request to like our page? ___Yes ___No FB Name: _________________________
Note: If you make a comment on our page about your treatment, we will send you a coupon for your
next session. Thank you for helping us grow.
Reason for visit
The reason for this visit is a result of (please circle):
work injury, sports, auto, trauma, chronic pain, relaxation, monthly wellness, birthday
In the past five years have you had any injuries?
______________________________________________________________________________
______________________________________________________________________________
If you have any ongoing pain in the body that is reoccurring, please describe the pain and its
location:_______________________________________________________________________
______________________________________________________________________________
When did the condition begin? ____/____/____
Is this condition getting worse? Yes No Constant Comes and goes
Is this condition interfering with your (please circle) work, sleep, or daily routine
If so, please explain: ____________________________________________________________
Have you been treated by a Medical Physician for this condition? Yes No
If so, where? ___________________________________________________________________