Beth Ann's Therapeutic Massage

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Welcome_Home

Did you Know?

Beth Ann Borecky is a Medical Massage Therapist

has been in practice for almost 25 years. And has been responsible for over 100 people learning to be Massage Therapists!

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Existing Patient Forms
1. We need your Name, DOB, and any Changes since your last appointment.
2. Please fill out the "Reason for the Massage Session Today" part, so the therapist knows what to focus on. And the Appointment Date.
3. Press Submit. This action takes you to the "Fast" Home page.

Please fill out:

* Indicates required field

Name *

First

Last

DOB (Date of Birth) (MM,DD,YYYY) *

Have there been any MEDICAL changes? *

No Yes

Non-Medical are like new Phone numbers, Occupations, emergency contacts, etc.

Have there been and non-Medical changes? *

No Yes

Email *

Reason for the Massage Session Today? *

Appointment Date & TIme *

Phone Number Day *

Day Phone Texts? *

Yes No

Phone Number Evening *

Evening Phone Texts? *

Yes No

Address *

Line 1

Line 2

City

State

Zip Code

Country

Are you: *

A minor (Under 18) 18 or Older

Minors must be accompanied by a Parent or Guardian. The Parent or Guardian must countersign all forms at the office and be present in the room during the Massage.

Occupation *

Employer *

Primary Physician (PCP) *

Emergency Contact *

Emergency Contact Relationship *

Emergency Contact Phone *

How did you hear about us? *

Medical Information Section

Currently under the care of? *

MD / DO / DC Other None

Care Persons Names? *

Conditions being treated for? *

Taking Medication? *

NO YES

Medications List - Both OTC (over-the-counter) and Prescription
Please list the Med Name, Strength, and When you take it: Skip a line between Meds

Name, Strength, Schedule *

Are You Pregnant *

No Yes

If yes, How far along? *

If Yes, List risk Factors (if any) *

Do you have Chronic Pain? *

No Yes

If Yes, Please Explain *

If Yes, What makes it Better *

If Yes, What makes it Worse? *

Orthopedic Injuries? *

No Yes

If Yes, Please list/Explain: *

Allergies? *

None Yes

Allergy List *

Sensitivities (Not Quite Allergies) *

None Yes

"Sensitive To" List *

Please indicate and conditions you have experienced in the last 2 years.
List current conditions at the top of this section. "A" and "B" just allows us to have two columns.

Conditions A *

None in this List Cancer Headaches Migrains Diabetes Joint Replacements High Blood Pressure Low Blood Pressure Neuropathy Fibromyalgia Stroke Left Side Stroke Right Side Heart Attack Kidney Disfunction Blood Clots Numbness Sprains Strains Fractures & Broken Bones Concussion Inactivity

Other Conditions not Listed? *

Conditions B *

None in this List Spinal Disorders Osteopososis Arthritis Injuries Swelling Pain Tingling Muscle Tension Sinus Problems Chronic Stress Heart Conditions (not Heart Attack) Varicose Veins Lung Conditions Digestive Problems Nervous Disorders Depression Surgery Skin Rashes Pregnancy

Submit

Images not created by us are: Pixabay Free for Commercial Use

Home
Welcome_Home

Did you Know?

Beth Ann Borecky is a Medical Massage Therapist

has been in practice for almost 25 years. And has been responsible for over 100 people learning to be Massage Therapists!

Existing Patient Forms1. We need your Name, DOB, and any Changes since your last appointment.2. Please fill out the "Reason for the Massage Session Today" part, so the therapist knows what to focus on. And the Appointment Date.3. Press Submit. This action takes you to the "Fast" Home page.

Please fill out:

Medical Information Section

Existing Patient Forms
1. We need your Name, DOB, and any Changes since your last appointment.
2. Please fill out the "Reason for the Massage Session Today" part, so the therapist knows what to focus on. And the Appointment Date.
3. Press Submit. This action takes you to the "Fast" Home page.