Page 1 - Client Info Form
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Client Information Form

IMPORTANT! PLEASE PRINT all your answers to questions and fill in all blanks completely. Thanks!

Name:                                                                Home Phone: (           )

Address:                                                             Work Phone: (        )

City:                                         Zip:                   Cell Phone: (     )

Date of Birth: ______/______/______ Height________ Weight________ Reminder Calls Phone: H___W___C___

Marital Status: S___M___D___W___ Home Email: (print)

Employer:                                               Job Title:

Address:                                                      City:                                 Zip:

Emergency Contact:                                                   Phone: (       )

                                              How did you find us?

Gold River Business Group___ Google___ Yahoo!___ Other Internet search___ Word-of-mouth___ Other___

Which Keywords? Myofascial Release___ Massage___ Massage Therapeutic___ Physical Therapy___

Who referred you?

                    General & Medical Information

Yes___No___ Have you ever experienced a professional myofascial release (MFR) or bodywork session?

What do you expect from your session today?___________________________________________________________________

If you answer “Yes” to any of the following questions, explain as clearly as possible at your first appointment.

Yes___No___ Do you frequently suffer from stress?                    Yes___No___ Do you have high blood pressure?

Yes___No___ Do you experience frequent headaches?                    Yes___No___ Are you diabetic?

Yes___No___ Do you have numbness or stabbing pains anywhere? Yes___No___ Do you have rheumatoid arthritis?

Yes___No___ Do you suffer from joint pain or swelling?               Yes___No___ Do you suffer from back pain?

Yes___No___ Have you had any joint replacements?                     Yes___No___ Do you have osteoporosis?

Yes___No___ Do you have any implants or prosthetics?                 Yes___No___ Have you ever had cancer?

Yes___No___ Do you have cardiac or circulatory problems?             Yes___No___ Do you have an aneurysm?

Yes___No___ Do you a history of blood clots?                         Yes___No___ Have you had any broken bones?

Yes___No___ Do you take Coumadin___ Heparin___?                      Yes___No___ Have you ever had surgery?

Yes___No___ Any accidents or injuries in the past two years?         Yes___No___ Allergic to creams, lotions or latex?

Yes___No___ Do you have any scars? Where?_____________________ Yes___No___ Are you depressed or sad?

Yes___No___ Do you suffer from epilepsy or seizures?                 Yes___No___ Do you have an IUD inserted now?

Yes___No___ Do you have urinary incontinence, urgency or frequency? Yes___No___ Are you pregnant?

Yes___No___ Do you have any contagious disease?                      Yes___No___ Do you have breast pain?

Yes___No___ Do you take any other medication? If yes, list. _______________________________________________________

           ________________________________________________________________________________________________

Yes___No___ Do you have any other medical condition of which I should be aware? If yes, explain._____________________

           ________________________________________________________________________________________________

                                                              (PLEASE GO TO PAGE TWO TO COMPLETE FORM)
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