Surveypoint

Q1

Name

First Name

Q2

Name

Last Name

Q3

Age

Q4

Date of Birth

Date

Q5

Email

Q6

Phone Number

Q7

Address

Street Address

Q8

Address

Street Address Line 2

Q9

Address

City

Q10

Address

State / Province

Q11

Address

Postal / Zip Code

Q12

Emergency Contact Name

First Name

Q13

Emergency Contact Name

Last Name

Q14

Relationship

Q15

Do you have any allergies?

Q16

Are you currently taking any medications?

Q17

Are you pregnant or nursing? (Female only)

Q18

Have you been recently hospitalized?

Q19

Do you have any current injuries?

Q20

Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?

Q21

Location of painful areas

Q22

I, undersigned, agree with the following statements:

Q23

Signature of the Client

Q24

Date Signed

Date

Massage Therapy Template 3 -Form Fill

Name

Name

Age

Date of Birth

Email

Phone Number

Address

Address

Address

Address

Address

Emergency Contact Name

Emergency Contact Name

Relationship

Do you have any allergies?

Are you currently taking any medications?

Are you pregnant or nursing? (Female only)

Have you been recently hospitalized?

Do you have any current injuries?

Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?

Location of painful areas

I, undersigned, agree with the following statements:

Signature of the Client

Date Signed