Name: __________________________________________________________________ Today's Date:_______________________

             (PLEASE PRINT: Last name, First Name) Date of Birth:________________________

Address:________________________________________________________________________________________________________________

Street Apt# City State Zip

Phone Number: Day(_____)____________________ Evening (_____)____________________ Cell (____)___________________

E-mail: __________________________________________

Did anyone refer you? _____________  Name:______________________________________________

Occupation:___________________________________ Employer:________________________________________________

What brings you in today?

Do you have any injuries, tender spots or scars? Please describe them.

What other types of Massage, Bodywork, or Therapy have you had?

Have you had any falls, major traumas to your body, or been in a car accident? Please describe.

Is there anything in your health history that your MassageTherapist should know about?

What types of exercise do you do? _____________________________________________________________________________

How often? ____________________________________________________________________________________________________

Are there any activities you can no longer do?   Yes __________   No __________

If yes, what are they? ___________________________________________________________________________________________

I understand that Back In Motion Integrative Therapy, may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.

Photographs taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below you consent to the use of these photographs in a professional manner.

I do hereby agree and give my consent for Back In Motion Integrative Therapy, to furnish care and treatment which is considered necessary and proper in the diagnosing or treatment of my physical conditions.

I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

I hereby certify that all the above information is true to the best of my knowledge.

Patient/Parent/Guardian Signature: ______________________________________   Date: __________________