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Your Name:
Email (required):
Zip Code:
Phone (home/work/cell):
Date of Birth:
Referred by:


Reason(s) for treatment, in order of discomfort:

When did you first notice the primary complaint?
Is this condition getting progressively worse? YesNo
What have you done to get relief?
Has there ever been a medical diagnosis? If so, what was it?

Additional Comments:

At your desk/workstation is your computer screen situated at or below eye level? YesNo
Is it situated directly in front of you, L/R? YesNo
Is your keyboard on your desktop or on an under your desk tray? YesNo
Is Your mouse on your desktop or on an under the desk tray? YesNo
Are you right handed? YesNo
How many hours a day are you seated? (Include time at work/school, in your car, watching television, eating, etc.)
How much of these do you consume daily?
- Water:
- Coffee/Tea?
- Soda/Diet Soda?
- Alcohol?
- Energy Drinks?
What medications are you currently taking?


Please read the following statements. By checking the box before each statement, you are in agreement of the statement.

Active Release Technique is a combination of Myofascial Release, Trigger Point Therapy and Deep Tissue Massage,among other things,with movement through assorted ranges of motion that helps lengthen the muscle to realign your body structurally. I understand that this technique is often painful and can create some discomfort.

I understand that professional draping will be used during all massage sessions.

I understand that the client has the right to end any massage session at any point during the massage for any reason.

I understand that massage therapy is not a substitute for medical examination and diagnosis. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder.

I have been provided with information relevant to treatment for the above listed complaint(s). Alternative courses of treatment where applicable and relevant as well as possible risks and side effects of the therapist proposed treatment plan, have been explained to me.

The consequences of having treatment/not having treatment have been explained to me.

Emergency Contact Name:
Emergency Contact Phone:

Patient Digital Signature (type full name):