New Client Form NameDate Date Format: MM slash DD slash YYYY What are your pronouns?Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary PhoneSecondary PhoneEmail OccupationEmployerEmergency ContactPhoneHow did you hear about us?WebsiteOtherReason for today's visit?Have you ever had a professional massage before?YesNoAre you pregnant or trying to get pregnant?YesNoIf yes, how far along are you?Please mark if you had any of the following conditions Heart Conditions Skin Disorders Diabetes Arthritis Broken Bones Sciatic Pain Neuropathies Dentures High Blood Pressure Immune Disorders Cancer Allergies Headaches Leg/Foot Pain Edema Wear Contacts Vascular/Blood Disorders Stomach Disorders Respiratory Disorders Back or Chest Aches Neck/Shoulder Pain TMJ Syndrome Breast Augmentation Allergies to Oils/Scents Herniated/Bulging/Degenerative Discs Radiation/Chemotherapy Treatment When? How long? DO YOU:Smoke?YesNoDrink Alcohol?YesNoDrink Caffeine?YesNoDrink Soda?YesNoEat Chocolate?YesNoUse lots of salt?YesNoWhat are your exercise/stretching habits?How many times per week?Duration?Please advise us any other healthcare professionals you have seen for this condition.Do you take any prescription medications?YesNoIf yes, please list them.Do you have any other medical issues including past surgeries or injuries that we should be aware of before giving you massage therapy? If yes, please describe: Please read the following:Consent*I understand that the Massage Therapist does not diagnose illness, disease, or any other physical or mental disorder, nor perform spinal adjustments. Massage therapy is not a substitute for medical examinations and/or diagnosis. It is recommended that I see a physician for any physical ailment that I might have. I understand that Massage Therapy given here is for the purpose of, but not limited to: fulfilling a prescription of a treating physician for a medically necessary condition, for relief from muscular spasm of fascial tension, or to improve circulation. Because a Massage Therapist must be aware of existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on my physical health. I agree understand.*CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Submit This iframe contains the logic required to handle Ajax powered Gravity Forms.