First Name
Last Name
Email address
*
Phone number
*
Emergency Contact
*
City
Medical Information
Are you taking any medication?
*
Yes
No
Please list medication name and use below:(In case of yes))
Are you currently pregnant?
*
Yes
No
How far along are you? (In case of Yes)
Do you suffer from chronic pain?
*
Yes
No
Please explain any chronic pain you suffer with below (In case of Yes)
Have you had any orthopaedic injuries?
*
Yes
No
Please list orthopedic injuries below (In case of Yes)
Please indicate any of the following that apply to you:
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
Explain any conditions you have marked above (If Marked)
Do you have any allergies or sensitivities
*
Yes
No
Please explain your allergies and/or sensitivities (In case of Yes)
By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
*
Clear
Signature date
*
Submit