Client Information New Client Information Name* First Last Date of Birth* MM slash DD slash YYYY Email* Home PhoneWork PhoneCell PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you locate me? Referring practitioner or physician? What motivates you to seek care at this time?*What would you like to receive from our work together(goals)?Have you previously had other bodywork? What type(s)? When?Are you currently seeing any other bodyworkers, therapists, etc.?With your consent, would you like me to consult with this person about your care?Areas of discomfort/tension (physical, emotional, mental, spiritual):What do you do to manage stress and stay connected to yourself?What form(s) of exercise do you do? Does it benefit you?Are you currently on a specific diet? Is it working well for you?Are you uncomfortable in any way with being touched?Do you have any history of abuse? (physical, sexual, emotional)?Is there anything regarding your family history that might be helpful for me to know that would support our work together?Medical HistoryMajor illnesses, past and present:Major injuries, past and present:SurgeriesName of Current Physician Conditions being treated if anyMedicationsEmailThis field is for validation purposes and should be left unchanged.