Name
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First Name
Last Name
Email
*
Phone
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
First Name
Last Name
Emergency Contact Number
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Date of Birth
MM
DD
YYYY
Occupation
What does your typical day involve?
(sitting at a computer, standing for long hours, playing sports, caring for children, caring for seniors, carrying heavy items, wearing dress shoes, etc)
Current injuries / health conditions
Past injuries / health conditions
Cancer history
Past/upcoming surgeries
Are you a cigarette smoker?
Please check any conditions that may apply to you
Are you currently pregnant or planning on becoming pregnant?
Please describe your exercise history
Current/past sports, exercise programs, or other physical activity
Please list any current medications
Are you currently receiving any forms of therapy?
Massage, Physical Therapy, Chiropractic, Acupuncture, etc
Chronic pains
If you are experiencing any chronic pains, please describe in as much detail as possible (location, cause if known, severity, etc)
What is your preferred scheduling for sessions
Weekdays, weekends; mornings, afternoons, evenings; or list specific days of the week/times.
What are your most important goals?
Please use this field to share any additional information you think is relevant.