Rosemont Pain Relief Therapy IMPORTANT! PLEASE COMPLETE THIS FORM Answer all question and fill-in all blanks. Thank you. Dennis Wilson Select a dateField is required!Field is required!Your InformationYour First NameField is required!Field is required!Your Last NameField is required!Field is required!Your E-mail AddressField is required!Field is required!Your Phone numberField is required!Field is required!Your Cell NumberField is required!Field is required!Reminder_Phone_NumberField is required!Field is required!Your AddressField is required!Field is required!CityField is required!Field is required!ZipcodeField is required!Field is required!- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonMarylandMassachusettsMichiganMinnesotaMississippiMissouriPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming- select a state -Field is required!Field is required!Emergency Contact InformationEmergency Contact InformationEmergency Contact InformationYour First NameField is required!Field is required!Your Last NameField is required!Field is required!Contact Phone NumberField is required!Field is required!EmploymentYour EmployerField is required!Field is required!your_positionField is required!Field is required!Your_Employers_AddressField is required!Field is required!Your Employer's CityField is required!Field is required!- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonMarylandMassachusettsMichiganMinnesotaMississippiMissouriPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming- select a state -Field is required!Field is required!Your Employers Zipcode:Field is required!Field is required!General and Medical InformationGeneral and Medical InformationGeneral and Medical InformationHeightHeightField is required!Field is required!WeightWeightField is required!Field is required!Birth DateSelect a dateField is required!Field is required!Are you currently experiencing any of the following conditions?Flu or Cold Inflammation Fever Infection Contagious DiseaseField is required!Field is required!Please check any of the following conditions below that currently affect you or that you have experienced in the past five years.Please check any of the following conditions below that currently affect you or that you have experienced in the past five years.MUSCULOSKELETALFibromyalgiaSpasms/cramps Sprains/StrainsOsteoporosisRheumatoid ArthritisPostural DeviationsGoutOsteoarthritisRheumatoid ArthritisTMJ Syndrome Joint Pain/Swelling BursitisPlantar FasciitisTendonitisTorticollisWhiplashCarpal TunnelSciaticaThoracic Outlet SyndromeHeadachesLeg PainArm Pain/Shoulder PainLow Back PainMid Back PainHip Pain OtherField is required!Field is required!CIRCULATORYAnemiaHemophiliaHypotensionHypertensionRaynaud’s SyndromeVaricose VeinsHeart ConditionBlood Clots DiabetesOtherField is required!Field is required!RESPIRATORYPneumoniaSinusitisAsthmaTrouble Breathing Dizziness/VertigoOtherField is required!Field is required!DIGESTIVEUlcersIBSColitisChron’s DiseaseDiarrheaGas/BloatingIndigestionOtherField is required!Field is required!SKINFungal InfectionsDermatitis/Eczema PsoriasisOpen Wound or SoreRashesAthletes FootOtherField is required!Field is required!NERVOUS SYSTEMALSMultiple SclerosisParkinson’s DiseaseBell’s PalsyNeuritisSpinal Cord InjuryStrokeTrigeminal NeuralgiaSeizure DisordersNumbness/Tingling/TwitchingOtherField is required!Field is required!OTHERInsomniaAnxiety/Panic Attacks PMSGrief ProcessCancerSubstance AbusePregnancyChronic FatigueHIV/AIDSLupus Kidney DiseaseBladder InfectionsPostoperative SituationEdemaStressImplants, Prosthetics, Joint ReplacementsUrinary Incontinence, Urgency, FrequencyScarsDepression/SadnessSurgeryOtherField is required!Field is required!Signature PageSignature PageSignature PagePlease take a moment to carefully read the following information and sign where indicated.I understand myofascial release/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware. I further understand that massage/bodywork practitioners do not diagnose physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because myofascial release/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I understand I will be CHARGED FOR APPOINTMENTS I CANCEL OR MISS WITHOUT 24 HOURS PRIOR NOTICE of my scheduled myofascial release/bodywork session. I also understand if I arrive late, I will receive the remainder of my time but will be liable for payment in full. I understand myofascial release/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware. I further understand that massage/bodywork practitioners do not diagnose physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because myofascial release/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I understand I will be CHARGED FOR APPOINTMENTS I CANCEL OR MISS WITHOUT 24 HOURS PRIOR NOTICE of my scheduled myofascial release/bodywork session. I also understand if I arrive late, I will receive the remainder of my time but will be liable for payment in full. SignatureYesNoField is required!Field is required!Field is required!Field is required!Select a dateField is required!Field is required!Thank youDennis Wilson Rosemont TherapyDennis Wilson<br /> Rosemont TherapySubmit
