Name

Birth Date

Address

Phone

Occupation

In case of emergency

How did you hear about Harmony Restored?

Gender Gender Male Female

When was your last massage?

Medications

Are you pregnant

Do you have high blood pressure

Do you have seizures

Have you had surgery?

Have you had a broken bone in the last 2 years

Do you have allergies

Do you have tension or soreness anywhere

What pressure would you like

Client Signature

Date