Kim Rogers, LMT
New Client Questionnaire
Name *
Your answer
Address *
Your answer
Contact Number *
Your answer
Email *
Your answer
Emergency Contact *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender Pronoun *
Your answer
Have you received massage therapy before? *
List any medications you’re currently taking that may influence today’s treatment:
Your answer
Have you had any injuries or surgeries in the past that may influence today’s treatment? If yes, please list below:
Your answer
Select any of the following health conditions that you currently have (if you are unsure, please ask) Please answer honestly as massage therapy may not be indicated for the following conditions:
Please list any current medical conditions (Please note: If you are experiencing any cold or flu symptoms now or in the future, for your health and ours, we ask that you reschedule your appointment until your symptoms have resolved) :
Your answer
List and prioritize any pain or dysfunction symptoms you are currently experiencing:
Your answer
How long have you been experiencing these symptoms?
Your answer
Do these symptoms interfere with you daily activities? If yes, explain:
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy