Your full name Your email Your telephone Street Address City State/Province Postal Code Country Date of Birth Occupation Physician Name Physician phone Emergency Contact Referred By Rate your current state of health from 1-10 12345678910 Have you ever had a professional massage? YesNo Describe injuries, concerns, or issues to address and causes and dates of concerns Describe any treatment you have received for these particular issues Describe your treatment goals Cardiovascular congestive heart failureembolismheart attackheart diseasehemophiliahigh blood pressurelow blood pressurepacemakerphlebitispoor circulationstrokethrombosisvaricose veinsfamily history Head and Neckdizzinessear problemsheadacheshearing lossjaw painmigrainesvision lossvision problems Musculoskeletal arthritisartificial jointbursitisosteoporosissurgical pin/wiretendonitis Neurological epilepsymultiple sclerosisnumbness/tinglingsensory loss/changesciaticaseizures