*First name:    *Last name:    *Occupation:

*Address:    *City:    *State:    Zip:

*Email:    *Phone:    *Date of birth:    *Gender: MaleFemale

*Name:    *Relationship:    *Phone:

If you currently have any areas of aches or pains, please describe:

Please list all current and past medical issues:
(Eg. Heart conditions, diabetes, musculoskeletal conditions, osteoporosis, high cholesterol, depression, anxiety, thyroid condition,cancer, infectious disease, rheumatoid arthritis. . .)

Please list any over-the-counter or prescription medications you are taking:

Please list any past surgeries (include dates):

Describe any physical activities at work, recreational activities and/or your current exercise routine:

Do you have any specific goals that you want to accomplish during your session?
(Eg. Improved flexibility, relaxation, injury prevention, reduced muscle soreness. . .)