Medical History Form

Massage Therapy Confidential New Patient Form

Please submit prior to your first appointment
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?

Natural Therapies PagesGoogleFacebookHealth ProfessionalFamily or FriendOther
Check the conditions that apply to you:*

Headache/MigraineNeck Pain/StiffnessShoulder Pain/StiffnessArm PainChest PainLower Back Pain/StiffnessUpper Back Pain/StiffnessHip Pain/StiffnessLeg PainAnkle/Foot Pain/StiffnessNumbnessPins and NeedlesMuscle CrampsLoss of StrengthArthritisLoss of BalanceDizzinessNausea/VomitingHeart ProblemsCirculation ProblemsCancerPsychiatric ConditionsAsthmaCardiac diseaseDiabetesHypertensionHepatitis/HIV/AIDSEpilepsyVaricose VeinsJoint ReplacementsBlood ClotsAllergiesMedication/DrugsSurgery/Broken Bones
Details of Above Conditions if any:
What is the reason for your treatment?
Should be Empty:

Massage Therapy Confidential New Patient Form