ࡱ> egdq` GbjbjqPqP -P::        FFFF\\}'8 OS%%%%%%%$(h+f&] WWW&  {&B!!!W  %!W%!!#   $ k%{iFFm #T$&}'#,+w(+ $+  $4WW!WWWWW&&! WWW}'WWWWd        OPTIMUM THERAPIES, LLC It s your choice, choose Optimum Therapies www.optimumtherapies.com MASSAGE REGISTRATION  Name:  FORMTEXT       FORMTEXT       FORMTEXT      Sex:  FORMCHECKBOX  Female  FORMCHECKBOX  Male First MI LastAddress:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Street City State ZipPhone (home):  FORMTEXT       (work): FORMTEXT      (cell):  FORMTEXT      E-mail address: May we contact you with news and special promotions? :  FORMCHECKBOX  Yes  FORMCHECKBOX  NoMarital Status:  FORMTEXT       Occupation  FORMTEXT      Date of Birth:  FORMTEXT      Stress Level: _____Low _____Medium _____High Reason for appointment? ___________________________________________How did you hear about Optimum Therapies?  FORMCHECKBOX  Friend f so, please share:  FORMTEXT       FORMCHECKBOX  Gift Certificate FORMCHECKBOX  Optimum Website FORMCHECKBOX  Community Event  FORMTEXT       FORMCHECKBOX  Yellow Pages FORMCHECKBOX  Drive By What type of exercise training do you partake in?  FORMTEXT       Have you seen a medical doctor within the last six months? :  FORMCHECKBOX  Yes  FORMCHECKBOX  No Primary Medical Physician: Chiropractor: Which of the following have you ever been diagnosed as having?  FORMCHECKBOX Cancer  FORMCHECKBOX Chemical Dependency  FORMCHECKBOX Other Arthritic Conditions  FORMCHECKBOX Heart Problems  FORMCHECKBOX Thyroid Problems  FORMCHECKBOX Anemia  FORMCHECKBOX High Blood Pressure  FORMCHECKBOX Diabetes  FORMCHECKBOX Hepatitis  FORMCHECKBOX Asthma  FORMCHECKBOX Multiple Sclerosis  FORMCHECKBOX Stroke  FORMCHECKBOX Emphysema/Bronchitis  FORMCHECKBOX Rheumatoid Arthritis  FORMCHECKBOX Other:  FORMTEXT ,.NT     0 2 ϸϸ|wphdYhKhphd@jh/UjhlUmHnHujh/UhljhlU hlhl h/5h5 (Hh{Ȧh5 B* CJOJQJphh5 B* CJOJQJph(Hh{Ȧh5 B* CJOJQJph,Hh{Ȧh5 B* CJ$OJQJaJ$ph2Hh{Ȧh5 h5 B* CJOJQJaJph,Hh{Ȧh5 B* CJ$OJQJaJ0ph. 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FORMCHECKBOX Dislocations  FORMCHECKBOX Fevers  FORMCHECKBOX Pulled Muscles  FORMCHECKBOX Fractures  FORMCHECKBOX Back Injuries  FORMCHECKBOX Recent Surgeries  FORMCHECKBOX Sore Arms  FORMCHECKBOX Neck Stiffness  FORMCHECKBOX Balance Problems  FORMCHECKBOX Numbness/Tingling  FORMCHECKBOX Swelling/Redness  FORMCHECKBOX Light Headedness  FORMCHECKBOX Nausea  FORMCHECKBOX Chronic Heartburn  FORMCHECKBOX Muscle Cramping  FORMCHECKBOX Low Back Pain  FORMCHECKBOX Mid-Back Pain  FORMCHECKBOX Pregnant Due Date:  FORMTEXT        FORMCHECKBOX Neck Injuries  FORMCHECKBOX Headaches DISCLOSURE STATEMENT: Massage therapy is a treatment modality designed for problems associated with the musculoskeletal system such as chronic muscle stiffness, loss of range of motion, chronic musculoskeletal pain, lymphatic retention and diminished bioenergy. Massage therapy is contraindicated under certain medical conditions, because of this, it is absolutely necessary for clients to disclose their medical history to their massage practitioner. Your signature represents your complete medical disclosure and your understanding that massage therapy is not a substitute for a medical examination, diagnosis, or treatment. 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