Therapist (Required)

Date Of Birth (Required)

Is this Massage/bodywork medically necessary (medical condition, injury, surgery)(Required)

Do you have physician referral/prescription?

Are you seeking insurance reimbursement?

Have you ever received massage/bodywork in the past (Required)

What kind of pressure do you prefer?(Required)

Do these symptoms interfere with you daily activities and lifestyle

Check if any of the following apply

Muscle or Joint Pain/Stiffness(Required)

Numbness or Tingling (Required)

Swelling (Required)

Bruise Easily(Required)

Sensitive to touch/pressure(Required)

High/Low blood pressure(Required)

Varicose Veins (Required)

Shortness of Breath (Required)

Cancer(Required)

Neurological (Multiple Sclerosis, Parkinson's, Epilepsy, Seizures)(Required)

Headaches/MIgraines(Required)

Dizness(Required)

Allergies(Required)

Digestive Issues (Crohn's, IBS, Gas, Bloating, Constipation)(Required)

Arthritis (Rheumatoid, Osteoarthritis)(Required)

Scoliosis(Required)

Broken Bones(Required)

Diabetes (Required)

Thyroid Conditions (Required)

Depression/Anxiety(Required)

Memory Loss/Confusion (Required)