Please print and bring to your first appointment. Write clearly . Thank you

                        Healing Horizons

                        Massage Therapy

Today's Date_____________DOB__________

First Name______________ Last Name_______________

Address______________________City_______________ST_____ Zip__________

Email(please provide):______________________Home Ph#____________

Work:______________ Cell_________________

How often do you use the phone or computer ? (circle)

everyday, sometimes,  never ,  a few hours.

Marital Status________ Referred by: _________________

google ,Citysearch, yahoo.local, other________

Have you ever received a professional massage before? 

 Y or N     How long ago? _______________  

Do you have any pain?   Y or No  Explain: ____________________________________________________

Do you have any of the following ?

Y   N   Do you suffer from Stress?        Y   N   Are you pregnant? 

 How many months?______

Y   N   Do you have Diabetes?             

Y   N   Do you experience headaches?        

Y   N  Do you Smoke? 

Y   N   Do you have arthritis?                    

Y   N   Do you bruise easily?  

Y   N   Do you drink water regularly?        

Y   N   Do you take vitamins supplements?

Y   N   Do you have high blood pressure?    

Y   N   Do you suffer from seizures or epilepsy?

Y   N   Do you have joint swelling?             

Y   N   Do you have osteoporosis?           

Y   N   Do you suffer from back pain        

Y   N  Do you have cardiac problems?     

Y   N  Do you have numbness or tinglinganywhere?____________

Y   N Are you sensitive to touch or pressure? 

       Where? ______________________                         

Y   N Do candles or scented lotions bother you ? 

Y   N  Do you have any other medical any other medical Condition I need to be aware of? _______________    

 Y   N  Have you broken any bones?

Y   N  Have you been in accident or

suffered any injuries in past two years? 

Where?________________________ 

I understand that massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will inform the therapist so that pressure or strokes may be adjusted to level of comfort. I understand that massage should not be construed as a substitute for medical treatment and that I should see a physician, chiropractor or other qualified medical specialist. I also understand that any illicit or sexually remarks or advances made will result in immediate termination of the session, and I will be liable for payment of the appointment.

Signature___________________________   Date______________

Consent to Treat a minor: By signing below I herby authorize massage.

Signature of parent or Guardian___________________ Date ___________