First and last name*

Mobile number*

Email address

Address

Apartment, suite or unit number

City

Date of Birth:

Preferred phone number:

Best time to call:

Preferred form of communication:

How did you hear about me? (referral, Facebook, etc.)

Is this a gift certificate?

Have you had a massage/bodywork before?

Frequency:

Types of massage/bodywork received:

Preferred types of massage:

Reasons for seeking massage? (relaxation, injury, etc.)

Description of injury/health condition:

Possible complications/medications:

Expected outcomes (functional improvement, symptom relief, wellness):

Typical activities of daily living (affected by condition?):

Occupation (affected by condition?):

Have you had a fever in the last 24 hours of 100°F or above?

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath

Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Do you have special needs I should prepare for:

Do you have any questions or concerns:

Additional Notes*