Health History Form

Please fill out this form and submit prior to your visit


Name *
Name
Date *
Date
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
Are you pregnant? *
Are you right or left handed? *
Please check all that apply:
Please read and check the box to confirm that you have read and agree to the terms: *

Your appointment time is reserved especially for you. If you find it necessary to re-schedule an appointment, a minimum of 24 hours notice is required; otherwise it will be necessary to charge you for the session time. Thank you for your cooperation and understanding. I am a Licensed Massage Therapist in the states of New York and Massachusetts as well as a Certified Trager® Practitioner and therefore comply with the ethical standards of these associations. I do not prescribe, diagnose or treat disease, nor is our work together a substitute for medical treatment or advice of a licensed physician.