Montana Myofascial Release Treatment Centers
Back In Motion Eastside PT & Body Restoration
612 1st Avenue South, Great Falls, MT 59401 101A Main Street, Stevensville, MT 59870
406-750-2655 Phone 406-777-2679 Fax (406)777-2676
Name: __________________________________________________________________ Today's Date:_______________________
(PLEASE PRINT: Last name, First Name) Date of Birth:________________________
Street Apt# City State Zip
Phone Number: Day(_____)____________________ Evening (_____)____________________ Cell (____)___________________
Did anyone refer you? _____________ Name:______________________________________________
What brings you in today?
Do you have any injuries, tender spots or scars? Please describe them.
What other types of Massage, Bodywork, or Therapy have you had?
Have you had any falls, major traumas to your body, or been in a car accident? Please describe.
Is there anything in your health history that your MassageTherapist should know about?
What types of exercise do you do? _____________________________________________________________________________
How often? ____________________________________________________________________________________________________
Are there any activities you can no longer do? Yes __________ No __________
If yes, what are they? ___________________________________________________________________________________________
I understand that Eastside PT & Body Restoration, may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.
Photographs taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below you consent to the use of these photographs in a professional manner.
I do hereby agree and give my consent for Eastside PT & Body Restoration, to furnish care and treatment which is considered necessary and proper in the diagnosing or treatment of my physical conditions.
I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.
I hereby certify that all the above information is true to the best of my knowledge.
Patient/Parent/Guardian Signature: ______________________________________ Date: __________________