New Patient Form for Massage Therapy
Since it is your first time to Simply Want It More Fitness you will need to fill out this questionnaire before your first session.
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Apt/Suite *
Your answer
P.O. Box *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Email *
Your answer
Occupation *
Your answer
How did you hear about S.W.I.M. Fitness? *
Who referred you?
Your answer
What is your reason for seeking massage therapy? *
Your answer
What is your current pain level? *
No Pain
Maximum Pain
Are you currently receiving treatment from other practitioners? *
Required
Emergency Contact *
Your answer
Phone Number *
Your answer
Relationship
Your answer
Do you take any medications or supplements? *
List separated by a comma, or type "None"
Your answer
Have you had any surgeries? *
Include date(s) or type "None"
Your answer
Significant Current and Previous Injuries *
Include date(s) or type "None"
Your answer
Are you pregnant? *
How frequently do you get massage therapy? *
Do you believe that massage therapy will help you? *
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