GENERAL INFORMATION
*Name: Date:
Address: City/State:
Zip: *Email:
*Home Phone: Cell:
Age: Birthdate:
mm/dd/yy
Gender: Marital Status:
Emergency Contact (Phone):    
Occupation: Company Name:
How did you hear about us? 
CONFIDENTIAL CASE HISTORY
Have you had massage therapy before? Yes No
What would you like to accomplish during your massage?
(specific pain reduction, general relaxation, increase range of motion)
What is your major area of pain/concern?
When did you first notice it?
What brought it on?
What activities aggravate it?
What have you done to get relief?
Has there been any of the following? (check all that apply)
Exam
Blood Work
Xrays
MRI
What was the diagnosis?
Other areas of pain concern:
PAST HISTORY
Have you ever had this problem before? Yes No
When?
What caused these episodes?
What relieved them?
What was the previous diagnosis?
By Whom?
What treatments did you have?
Did they help? Yes No
Are you presently under a doctor's care? Yes No
If yes, for what condition?
Name of Physician:
City: State: Phone:
Medications:
Please list:  
Previous operations or cosmetic surgeries, dates?
Previous broken bones or dislocations?
Previous accidents or injuries?
Enter 'C' for all of the following that you are currently having difficulty with. Enter 'P' for any you have had past problems with.
C=Current problems
P=Past problems
Low back pain Arthritis Digestive disorder Thyroid disease
Mid back pain Bursitis Constipation Stress
Tight Shoulders High Blood Pressure Ulcers Allergies
Stiff neck Low Blood Pressure Nervousness Sinusitis
Feet pain Asthma Depression Diabetes
Joint pain Skin disorders Dizziness Hepatitis
Sciatic pain Varicose veins Chronic fatigue Edem
TMJ pain Phlebitis Herniated disc Tuberculosis
Headaches Poor Circulation Stroke Cancer
Parkinsons Disease Numb hands/feet Cerebral Palsy Insomnia
Recent surgery Recent injury Fibromyalgia Hernia
Multiple Sclerosis Nounion fracture Epilepsy Heart attack
HIV contact Sciatica Swollen joints Painful joints
Chest pain Muscle spasms Anemia  
Other
GOALS
In your own words or with the examples stated below, please list your top three goals, e.g.: Look Better (Lower Body Fat, Muscle Definition or Mass, Girth Changes) Feel Better (Education, Energy, Decrease Pain, Feeling of Health) Perform Better (Cardiovascular Conditioning, Flexibility, Muscular Strength and/or Endurance, Sport-specific Results, Improve Medical Problems)

*I understand that payment is due at the time of treatment unless prior arrangements have been made.

*I agree to give 24 hours notice of cancellation or change of appointment. if less than 24 hours notice is given, I agree to pay for the session if Peak Performance is unable to fill the appointment time with another person. (Cases of extreme emergency are considered exceptions.)
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