Personal Information
Name *
Name
Address *
Address
Phone *
Phone
Social Security Number
Birthdate *
Birthdate
Have you ever received a professional massage? *
Why did you come for our service? *
Marital Status *
Emergency Contact *
Emergency Contact
Emergency Contact Phone Number *
Emergency Contact Phone Number
Spouse's Name (if applicable)
Spouse's Name (if applicable)
Spouse's Phone Number (if applicable)
Spouse's Phone Number (if applicable)
Employer Address
Employer Address
Employer Phone
Employer Phone
Health Survey
What treatments have you already received for your condition? *
Types of pain you are experiencing? *
Does it interfere with your: *
Activities or movements that are difficult to perform: *
Please check any conditions you have experienced in the past or present: *
Primary Care Physician's Name *
Primary Care Physician's Name
Primary Care Physician's Phone Number *
Primary Care Physician's Phone Number
Primary Care Physician's Address *
Primary Care Physician's Address
Insurance Information
Who is financially responsible for this account? *
Who is financially responsible for this account?
Is client covered by additional insurance? *
Is this condition related to an accident? *
Type of accident (if applicable)
To whom have you made a report of your accident? (if applicable)
Attorney Name (if applicable)
Attorney Name (if applicable)
Attorney Phone Number (if applicable)
Attorney Phone Number (if applicable)