FST Health History Name(Required) First Name Last Name Phone(Required)Email(Required) Birth Date(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City StateAlabamaAlaskaAmerican 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 Please check all that apply and explain on back if necessary: Immune Disorder Heart Problems Chest Pains/Palpatations High/Low Blood Pressure Severe Dizziness/Feeling Faint Digestion Problems Blood Clots Arthritis/Bursitis Osteoporosis Sciatica Respiratory Problems Cancer Diabetes Epilepsy Emphysema Stroke Current Pregnancy Surgery Flu-like symptoms (covid-19) High Cholesterol Pain in Knees Pain in Shoulders Pain in Elbows Pain in Wrists Pain in Ankles Chronic Back Pain TMJ Elimination Problems Sinus Problems Neck Problems Tendonitis Ulcers Cold Hands/Feet Bruise Easily Allergies Fibromyalgia Carpal Tunnel Asthma Immovable Joints Scoliosis SI Joint Pain Migraines Recent Injury I sit most of the day I stand most of the day I do manual labor most of the day Other: If you checked any options above, please explain any details that may affect your session:Do you have any health problems not listed above that may affect your session?Are you currently being treated by a physician, massage therapist, chiropractor, etc for any condition?Are you currently taking any medication that may affect your session?What would you most like to receive from your FST session?The above information is accurate and true to the best of my knowledge. If there are any changes in my current level of health, I will inform the practitioner of my condition. I understand that this practitioner does not diagnose or treat illness or disease and does not prescribe medications. I understand that close contact with people increases the risk of infection from Covid-19. I acknowledge that I am aware of the risks involved and give consent to receive Fascial Stretch Therapy from this practitioner. It is agreed that any claim of liability is hereby waived.SignatureCAPTCHANameThis field is for validation purposes and should be left unchanged.
