1. NAME (required):
ADDRESS (required):
CITY (required):
STATE (required):
ZIP (required):
EMAIL (required):
MAIN PHONE (required):
WORK PHONE:	Format: (xxx) xxx-xxxx
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:
28. Age Certification:	Over 18 Years   Under 18 Years
	I certify that I am over the age of 18 years and that I do not suffer from any physical or mental disability that might affect my participation in the Massage Therapy process, and, if I have any substance abuse problem, injury, condition or illness of any kind, I have consulted with my physician and/or other health care professional and been advised that I may participate in the Massage Therapy process without risk, or I agree that if there is any change in this representation, I will promptly advise the Massage Therapist. I understand that the massage therapy performed will be for the purpose of stress reduction, relief from pain, muscular tension or spasm, or for increasing circulation and energy flow. I understand that the massage therapist does not diagnose illness,disease or any other physical or mental disorder. As such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor does he/she perform any spinal manipulations. It has been made clear to me that massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have. Because a massage therapist must be aware of existing physical conditions, I have stated all my known medical conditions and take it upon myself to update the massage therapist about my physical health. By clicking on submit, I understand that I have read, understood and agree to the terms above. Signature: _________________________ Date: _________________________
	I certify that I am the legal guardian of who is under the age of 18 years and I understand that any care provided for my (son/daughter/ward) must be conducted with the myself present in the treatment room. I certify that my (son/daughter/ward) does not suffer from any physical or mental disability that might affect his/her participation in the Massage Therapy process, and, if they have any substance abuse problem, injury, condition or illness of any kind, I have consulted with their physician and/or other health care professional and been advised that they may participate in the Massage Therapy process without risk, or I agree that if there is any change in this representation, I will promptly advise the Massage Therapist. I understand that the massage therapy performed will be for the purpose of stress reduction, relief from pain, muscular tension or spasm, or for increasing circulation and energy flow. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. As such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor does he/she perform any spinal manipulations. It has been made clear to me that massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that my (son/daughter/ward) see a physician for any physical ailment that they might have. Because a massage therapist must be aware of existing physical conditions, I have stated all the known medical conditions of my (son/daughter/ward) and take it upon myself to update the massage therapist about their physical health. By clicking on submit, I understand that I have read, understood and agree to the terms above. Signature: _________________________ Date: _________________________