Pre-Visit Form For your convenience, please complete our pre-visit questionnaire to save time on your first visit. 1Contact2Questions3Health4Final Questions Name First Last PhoneEmail Address Street Address City ZIP Code Occupation Employer Date of Birth MM slash DD slash YYYY Referred By Primary Reason For MassageHave You Ever Had A Professional Massage Before?If So, Was There Something Special You Enjoyed?How Would You Describe Your General Health? Excellent Good Fair Poor Have You Ever Been Hospitalized? Yes No Date of Hospitalization MM slash DD slash YYYY If Yes, Please Describe Are You Currently Under The Care Of A Physician? Yes No If Yes, Please DescribePhysician's Name Number When Was Your Last Examination? MM slash DD slash YYYY Please Check If You Have Any Of The Following Joint Disease Chronic Fatigue Sysndrome Depression Digestive Problems Irritiable Bowel Sydrome Asthma Tightness of Throat Hernia/Rupture Abdominal Pain Arthritis Heart Disease High / Low Blood Pressure Anemia Bruise Easily Phlebitis / Thrinbosis Stroke Varicose Veins Chest Pains Dizziness / Loss of Balance Diabetes / Hypoglycemia Numbness / Coldness of Extremities Cancer Hepatitis Kidney Disease Muscular / Skeletal Injuries Skin Problems Carpal Tunnel Syndrome Constipation Insomnia Bladder Problems Painful Menstriation Ringing in Ears Seizures Fatigue Blood Clots Dislocation Spinal Problems Osteoporosis Poliomyelites Fibromyalgia Allergies Sinusities Dental Problems Headaches / Migraines HIV Virus / Aids Edema Pregnant Recurring Indigestion Other ( List Below ) Other Media Issues Please List Any Significant Bodily InjuriesEven in childhood, accidents, sprain, falls, bone fractures, etc.Do You Wear Contact Lenses Are You Currently Taking Any Over The Counter Or Prescription Medications?Please Describe Any Current Medications And Reasons For UseDo You Have, Or Have You Had Any Other Medical Condition, Sympton, Or Problem With Regard To Your Health, Fitness, or Any other Structural Condition That I Should Be Aware Of Prior To Administering Massage Therapy? Please Describe. Online Form – American Therapeutic Massage-Client Information
