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First Name
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Last Name
Phone Number
Zip*
Confirmation Preference
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How did you hear about us?
Another Client
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Local Business
Next to CVS
Physical Therapy
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If another client, Business, or other, please specify
Have you ever had a professional massage?
Yes
No
If yes, when and where?
What specific areas would you like your therapist to concentrate on?
[anatomy]
Are there any areas you do NOT want massaged?
Yes
No
If yes, please list:
What are your goals at Sandstone? (choose all that apply)
Relaxation & Swedish Massage
Focused Therapeutic Massage
Pain/Injury Rehabilitation
Facials & Skin Care
Holistic Therapies
Nutrition & Wellness Consultations
On a scale from 1-10 are you experiencing any pain today?
1
2
3
4
5
6
7
8
9
10
Is this visit due to the following?
Birthday
Car Accident
Celebration
General Pain
Gift Certificate
Personal Injury
Stress
Workers Comp Injury
Other
Health History ( select all that apply)
Anxiety
Arthritis
Artificial Joints
Autoimmune Disease(s)
Blood Clots
Blood Thinners
Bruises Easily
Cancer (active/remission)
Circulation Disorder
Depression
Diabetes
Fibromyalgia
Hearing Impaired
Heart Condition
High blood pressure
High Stress
Hypermobility
Jaw Clenching/ Tension
Low Blood Pressure
Migraines/Headaches
Numbness/Tingling
Open Wounds
Seizures
Skin Disorders
Strokes/TIA'S
Swelling
Other
N/A
