Focused Intention, LLC Medical History Form
Date *
MM
/
DD
/
YYYY
Referred By
Name *
Birthdate *
MM
/
DD
/
YYYY
Occupation *
Address/City/State/Zip
Home Phone Number
Cell Phone *
Email *
Primary Care Physician *
Date of Last Physical
MM
/
DD
/
YYYY
Medications (enter "none" if appropriate) *
What is your previous massage experience? *
What is your reason for choosing massage? *
What results do you expect to get from this treatment? *
Select any/all of the following conditions that pertain to your health status:
Please explain any condition that you checked above:
List any and all Allergies?
Other (include any other conditions, syndromes, recent accidents and anything else pertinent to your health status):
Please explain where your pain is and where you hold your tension; be as specific as possible (eg, left side, right side, front or back):
Please list any medical history updates (including dates if possible):
Submit
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