New Patient Form New Patient Form Step 1 of 2 50% Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birth Date* Home or Cell Phone*In case of emergency contact* First Last Emegency contact phone*Are you experiencing pain, numbness or tension?* Yes No Please indicate where*Headaches* Yes No Arthritis* Yes No High Blood Pressure* Yes No Epilepsy* Yes No Joint Pain or Swelling* Yes No Varicose Veins* Yes No Osteoporosis* Yes No Allergies* Yes No Ever been in an accident or suffered an injury?* Yes No Do you have numbness or stabbing pain?* Yes No Have you ever had a surgery?* Yes No Do you have diabetes?* Yes No Are you pregnant?* Yes No Do you have cardiac or other circulatory problems?* Yes No Are you currently taking any medication?* Yes No Please list the medications you are currently takingPlease list any other medical conditions I should be aware ofHow did you hear about us?I recognize that the massage therapist is a certified licensed professional. I understand that massage therapists are not qualified to perform skeletal adjustments, diagnose, prescribe or treat any physical or mental illnesses. I have stated all my known medical conditions and take it upon myself to keep my therapist updated on my physical or mental illnesses. All Body Care associates are not liable for any misrepresentation concerning the above questions.Please acknowledge the above statement before submitting your form* I agree