Register Therapist NotesPersonal InformationUsername First Name Last Name E-mail Address Password Confirm PasswordPhone (day) Phone (night) DOB Address: City/State/Zip Occupation Employer Primary Physician Emergency Contact Relationship How did you hear about us?Medical InformationAre you taking any medication?YesNoIf yes, please list name and use:Are you currently pregnant?YesNoIf yes, how far?Any high risk factors?Do you suffer from chronic pain?YesNoIf yes, please explainWhat makes it better?What makes it worse?Have you had any orthopedic injuries?YesNoIf yes, please list:Please indicate any of the following that apply to you.CancerHeadaches/MigrainesArthritisDiabetesJoint Replacement(s)High/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or StrainsExplain any conditions you have marked above:Massage InformationHave you had a professional massage before?YesNoWhat type of massage are you seeking?RelaxationTherapeutic / Deep TissueOther:What pressure do you prefer?LightMediumDeepDo you have any allergies or sensitivities?YesNoPlease Explain:Are there any areas (feet, Face, abdomen, etc.) you do not want massaged?YesNoPlease Explain:What are your goals for this treatment session?Please select any areas of discomfort on the front of your body.Head - LeftHead - RightShoulder - LeftShoulder - RightArm - LeftArm - RightChest - LeftChest - RightAbs - LeftAbs - RightUpper Leg - LeftLower Leg - RightPlease select any areas of discomfort on your back:Head - LeftHead - RightShoulder - LeftShoulder - RightArm - LeftArm - RightUpper Back - LeftUpper Back - RightLower Back - LeftLower Back - RightUpper Leg - LeftUpper Leg - RightCalf - LeftCalf - RightBy signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.Client Signature: Only fill in if you are not human Login
