Download, Print and Complete the Health History form here, or complete the below online form.

Your Name(*)
Please type your full name.

Service Provider Name
Invalid Input

Date(*)
Invalid Input

Mailing Address(*)
Invalid Input

City / State / Zip(*)
Invalid Input

Email(*)
Invalid Input

Date of Birth(*)
Invalid Input

Phone(*)
Invalid Input

Part A: Massage & Bodywork
Do you have a prescription for massage?(*)
Invalid Input

Have you ever had a professional massage?
Invalid Input

How Often?(*)
Invalid Input

Any experience with alternative / holistic care?(*)
Invalid Input

What Type and How often?(*)
Invalid Input

List any allergies to oils, lotions or scents(*)
Invalid Input

Is there anything you would like to know more about regarding wellness?
Invalid Input

Part B: Medical History
Are you currently under the care of a physician or specialist?(*)
Invalid Input

Reason?
Invalid Input

May we contact your physician?(*)
Invalid Input

Physician Name
Invalid Input

Physician Phone No.
Invalid Input

Are you taking medications, including over the counter?(*)
Invalid Input

Please list all medications
Invalid Input

List any allergies you have, including food allergies
Invalid Input

Please indicate any conditions that apply to you by writing the date and frequency of condition.
Musculo-Skeletal System
Osteoporosis
Invalid Input

Back Pain
Invalid Input

Broken/Fractured Bones
Invalid Input

Arthritis
Invalid Input

Sprains / Strains
Invalid Input

Headaches
Invalid Input

Spasms / Cramps
Invalid Input

TMJ Dysfunction
Invalid Input

Other Musculo-Skeletal System
Invalid Input

Circulatory / Respiratory System
Heart Condition
Invalid Input

Varicose Veins
Invalid Input

High / Low Blood Pressure
Invalid Input

Blood Clots
Invalid Input

Asthma
Invalid Input

Sinus Problems
Invalid Input

Other Circulatory / Respiratory System
Invalid Input

Nervous System
Numbness / Tingling
Invalid Input

Fatique
Invalid Input

Sleeping Disorder
Invalid Input

Depression / Anxiety
Invalid Input

Other Nervous System
Invalid Input

Skin
Skin Allergies
Invalid Input

Psoriasis
Invalid Input

Eczema
Invalid Input

Dermatitis
Invalid Input

Fungus
Invalid Input

Other Skin
Invalid Input

Digestive System
Abdominal Pain
Invalid Input

Nausea
Invalid Input

Bloating
Invalid Input

IBS
Invalid Input

Other Digestive System
Invalid Input

Are you expecting?
Invalid Input

If so, how many weeks?
Invalid Input

Invalid Input

PMS
Invalid Input

Miscellaneous
Autoimmune Disorders
Invalid Input

Cancer
Invalid Input

Diabetes
Invalid Input

Other Miscellaneous
Invalid Input

Part C Acknowledgement & Consent
Signature: Please type your full name(*)
Invalid Input

Enter Security Code(*)
Enter Security Code
  Get New CodeInvalid Input

creditcard    jointeam bookappt 
 Buy Gift Cards      Join Our Team  Book Appointment    

Newsletter Signup

First time customer? Signup for our Newsletter and receive an email with a $10.00 coupon to be used towards your first appointment with us!
Full Name(*)
Please type your full name.

Phone(*)
Invalid Input

E-mail(*)
Invalid email address.

Birthday
Invalid Input

Enter Code(*)
Enter Code
Invalid Input