1. NAME (required):
ADDRESS (required):
CITY (required):
STATE (required):
ZIP (required):
EMAIL (required):
MAIN PHONE (required):
WORK PHONE:
CELL PHONE:
HOME PHONE:
OTHER PHONE:
URL:
2. I prefer to have appointments confirmed:	Main   Work   Cell   Home   Other   Text   Email
3. Date of Birth:
4. Children:	Yes   No
Names & Ages (optional):
5. Emergency Contact Name:
Emergency Contact Phone:
Relationship:
6. Physician's Name:
Physician's Phone:
Permission to Call:	Yes   No
7. How did you hear about TouchFitness?	Ad   Coupon   Web Referral   Other
How did you hear about us?
8. Preferred Pressure:	Light   Medium   Deep Mixed Pressure
9. Prefer:	Cold   Heat
10. Preferred Music:	Classical   Alternative   Etherial Custom   Guided Relaxation   Other
11. Preferred Options:	Oil   Cream   Scented Unscented   None
12. What kinds of massage have you had?
13. Comments/Likes/Dislikes:
14. Do you have any sensitivities or allergies to essential oils, massage oils or creams?	Yes   No
Please describe your allergies or sensitivities:
15. What is the primary reason for your visit?
16. Please list any secondary considerations or concerns:
17. Please list the dates and treatments for any injuries, accidents, surgeries and/or fractures:
18. Please list the physical activities associated with your occupation:
19. List any discomforts you may feel from your occupation:
20. List activity and frequency of exercise or athletic involvement:
21. List any discomforts or injuries you are experiencing from exercise or athletics:
22. Number per day of:	Cigarettes   Coffee Alcohol   Other
23. Are you pregnant?	Yes   No
Number of months:
Is this your first pregnancy?	Yes   No
24. Do you have any metal rods, pins, plates, pacemaker surgically implanted in your body?	Yes   No
If so, where?
26. Please check off any current conditions and/or any previous conditions:	Asthma   Herpes Rheumatoid Arthritis   Cancer Hypertension   Scoliosis Colitis   Lipomas Shingles (H. Zoster)   Diabetes Lyme Disease   Swelling in Joints Dizziness   Multiple Sclerosis Tuberculosis   Epilepsy Osteoporosis/Arthritis   Ulcers Heart Disease   Psoriasis/Excema Varicose Veins
27. List any medications, supplements, vitamins or herbs you are currently using: