Name: ___________________________________________________________ Date: __________________ Address: _________________________________________________________________________________ Birthday: ______________________ Occupation: _______________________________________________ Phone Number: _____________________ Email: _______________________________________________ Emergency Contact (name and phone): ______________________________________________________ Would you like to receive emails letting you know of promotions or changes? Y / N Allergies? __________________ Prescription Medications? ______________________________________ Surgeries/Falls/ Accidents (last 5 years)? _____________________________________________________ _________________________________________________________________________________________ Are you being treated by other Healthcare Professionals? ______________________________________ Medical Implants/Wires? ___________________________________________________________________ Diagnoses/Illnesses/Concerns? _____________________________________________________________ Overall, how do you feel about your health? __________________________________________________ What pressure do you prefer for your massage? Lighter Medium Firm Please circle any areas of discomfort, and elaborate below if need: ____________________________________________________
2
Embed
High Blood Pressure Emphysema Shortness of Breath · High Blood Pressure Emphysema Shortness of Breath Varicose Veins/Phlebitis Chronic Congestive Heart Troubled Skin Low Blood Pressure
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.