New Client Form

Name *

First Name

Last Name

Phone *

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Please select conditions that you are currently experiencing or have experienced within the last 12 months. *

Seasonal Allergies

Asthma

Hypoglycemia

High Blood Pressure

Blood Clots

Heart Disease

Kidney Dysfunction

Varicose Veins

Bursitis

Spine / Neck Injury

Strains / Sprains

Broken / Fractured Bones

Fibromyalgia

TMJ Syndrome

Eczema

Rashes

Migraines

Headaches

Insomnia

MS

Phlebitis

Stroke

Osteoarthritis

Cancer

Psoriasis

Chrone Fatigue Syndrome

Compromised Immune System

Osteoporosis

Muscle Cramps

Numbness

Tingling

Carpel Tunnel Syndrome

Digestive Disorders

Rheumatoid Arthritis

Diabetes

Flu / Cold / Fever

Dermatitis

Celiac Disorder

Irritable Bowel Syndrome

HIV / AIDS

Liver Disorder

Plantar Fasciitis

Sciatica

Respiratory Disorder

Thyroid Disorder

Gout

Tendinitis

Depression

Eating Disorder

Pregnancy

PMS

Menopause

Pelvic Inflammatory Disease

Endometriosis

Hysterectomy

Fibroids

Fertility Concerns

Prostate Problems

I understand that if I experience any pain or discomfort during my session, I will immediately inform the therapist. *

I Accept

I understand that massage should not be considered a substitute for medical examination, diagnosis or treatment. *

I Accept

I agree to seek qualified medical care for any mental or physical illness that I am experiencing. *

I Accept

I also understand that certain contraindications exist for massage therapy and I will inform my massage therapist immediately if any changes to my health profile occur. *

I Accept

Date *

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