{"id":1157,"date":"2025-07-07T13:25:24","date_gmt":"2025-07-07T13:25:24","guid":{"rendered":"https:\/\/testv80.demowebsitelinks.com\/TMMTV1\/?page_id=1157"},"modified":"2025-08-08T13:58:37","modified_gmt":"2025-08-08T13:58:37","slug":"new-client-intake-form-2","status":"publish","type":"page","link":"https:\/\/testv80.demowebsitelinks.com\/TMMTV1\/new-client-intake-form-2\/","title":{"rendered":"New Client Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1157\" class=\"elementor elementor-1157\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1d1077d e-flex e-con-boxed e-con e-parent\" data-id=\"1d1077d\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-3a4ce2e e-con-full e-flex e-con e-child\" data-id=\"3a4ce2e\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-18f55e7 elementor-view-default elementor-widget elementor-widget-icon\" data-id=\"18f55e7\" data-element_type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<div class=\"elementor-icon\">\n\t\t\t<i aria-hidden=\"true\" class=\" sicon-sunlit\"><\/i>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c6c739c elementor-widget elementor-widget-gva-heading-block\" data-id=\"c6c739c\" data-element_type=\"widget\" data-widget_type=\"gva-heading-block.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"gva-element-gva-heading-block gva-element\">   <div class=\"align-left style-1 widget gsc-heading box-align-left auto-responsive\">\r\n      <div class=\"content-inner\">\r\n         \r\n                  \r\n           \r\n         \r\n                     <h2 class=\"title\">\r\n               <span>New Client Intake Form<\/span>\r\n            <\/h2>\r\n         \r\n                  \r\n         \r\n         \r\n      <\/div>\r\n   <\/div>\r\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-bce13a1 e-flex e-con-boxed e-con e-parent\" data-id=\"bce13a1\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-d9be2d8 e-con-full e-flex e-con e-child\" data-id=\"d9be2d8\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-99cfacd elementor-widget elementor-widget-gva-heading-block\" data-id=\"99cfacd\" data-element_type=\"widget\" data-widget_type=\"gva-heading-block.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"gva-element-gva-heading-block gva-element\">   <div class=\"align-center style-1 widget gsc-heading box-align-center auto-responsive\">\r\n      <div class=\"content-inner\">\r\n         \r\n                  \r\n         <div class=\"sub-title\"><span class=\"tagline\"><span class=\"tagline-icon\"><i aria-hidden=\"true\" class=\"sicon-sunlit\"><\/i><\/span>Helpful Forms<\/span><\/div>  \r\n         \r\n                     <h2 class=\"title\">\r\n               <span>New Client Intake Form<\/span>\r\n            <\/h2>\r\n         \r\n                  \r\n         \r\n         \r\n      <\/div>\r\n   <\/div>\r\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-dc874e8 elementor-widget elementor-widget-shortcode\" data-id=\"dc874e8\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/TMMTV1\/wp-json\/wp\/v2\/pages\/1157' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_44\"  class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\"><label class='gfield_label gform-field-label' for='input_1_44' >CLIENT #<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_1\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\"><p>( For Office Use Only )<\/p><\/div><div id=\"field_1_43\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\"><h2>NEW CLIENT INTAKE FORM<\/h2>\n<h4>MASSAGE THERAPY SERVICES<\/h4>\n<br>\n<p>1st Appointment for New Client will require approximately 15 minutes to review all submitted forms, answer any questions, concerns, goals and review the treatment plan, 5 minutes for client to change for the massage therapy session. 1st Appointment Massage Therapy session will be  approximately 15 minutes less than scheduled time. Full massage therapy service fee is in effect.<\/p>\n<br>\n<h5>PERSONAL INFORMATION<\/h5><\/div><fieldset id=\"field_1_3\"  class=\"gfield gfield--type-name gfield--width-quarter field_sublabel_hidden_label gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_3'>\n                            \n                            <span id='input_1_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Name<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_1_4\"  class=\"gfield gfield--type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\"><label class='gfield_label gform-field-label' for='input_1_4' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\"  class=\"gfield gfield--type-email gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\"><label class='gfield_label gform-field-label' for='input_1_5' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_42\"  class=\"gfield gfield--type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\"><label class='gfield_label gform-field-label' for='input_1_42' >CLIENT #<\/label><div class='ginput_container ginput_container_number'><input name='input_42' id='input_1_42' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_1_6\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_1_6_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_6_1' id='input_1_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_1_6_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_6_3' id='input_1_6_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_6_4_container' >\n                                        <input type='text' name='input_6.4' id='input_1_6_4' value=''      aria-required='false'    \/>\n                                        <label for='input_1_6_4' id='input_1_6_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_1_6_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_6_5' id='input_1_6_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_1_6_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_7\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\"><label class='gfield_label gform-field-label' for='input_1_7' >DOB<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_8\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\"><label class='gfield_label gform-field-label' for='input_1_8' >Emergency Contact<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_9\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\"><label class='gfield_label gform-field-label' for='input_1_9' >Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_10\"  class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\"><label class='gfield_label gform-field-label' for='input_1_10' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_1_10' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_11\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\"><label class='gfield_label gform-field-label' for='input_1_11' >How Did You Hear About Us?<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_12\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\"><h4>MEDICAL INFORMATION<\/h4><\/div><fieldset id=\"field_1_13\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\"><legend class='gfield_label gform-field-label'  >Are you taking any medications?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_13'>\n\t\t\t<div class='gchoice gchoice_1_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_1_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_0' id='label_1_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_1_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_14\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\"><label class='gfield_label gform-field-label' for='input_1_14' >If yes, please list<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_15\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\"><legend class='gfield_label gform-field-label'  >Are you currently pregnant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_15'>\n\t\t\t<div class='gchoice gchoice_1_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_1_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_0' id='label_1_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_1_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_16\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\"><label class='gfield_label gform-field-label' for='input_1_16' >If yes, please list<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_17\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\"><label class='gfield_label gform-field-label' for='input_1_17' >Any high risk factors?<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\"><legend class='gfield_label gform-field-label'  >Do you suffer from chronic pain?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_18'>\n\t\t\t<div class='gchoice gchoice_1_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_1_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_1_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_19\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\"><label class='gfield_label gform-field-label' for='input_1_19' >If yes, please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_1_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_20\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><label class='gfield_label gform-field-label' for='input_1_20' >What makes it worse?<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_21\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\"><legend class='gfield_label gform-field-label'  >Do you currently have any injuries?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_21'>\n\t\t\t<div class='gchoice gchoice_1_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_1_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_1_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_22\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><label class='gfield_label gform-field-label' for='input_1_22' >If yes, please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_36\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\"><legend class='gfield_label gform-field-label'  >Are you currently under the care of a physician, chiropractor, physical therapist, counselor<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_36'>\n\t\t\t<div class='gchoice gchoice_1_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_1_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_0' id='label_1_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_1_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_37\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\"><label class='gfield_label gform-field-label' for='input_1_37' >Provider Name<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_1_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_38\"  class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\"><label class='gfield_label gform-field-label' for='input_1_38' >Office Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_1_38' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_39\"  class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\"><label class='gfield_label gform-field-label' for='input_1_39' >The condition(s) for which treatment or care is being sought<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_1_39' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_40\"  class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\"><label class='gfield_label gform-field-label' for='input_1_40' >When was the onset of the condition(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_1_40' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_41\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\"><label class='gfield_label gform-field-label' for='input_1_41' >Is your current treating provider aware that you are receiving massage therapy service?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_1_41' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_23\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Please indicate any of these conditions that apply to you:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_23'><div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Cancer'  id='choice_1_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Headaches\/Migraines'  id='choice_1_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_2' id='label_1_23_2' class='gform-field-label gform-field-label--type-inline'>Headaches\/Migraines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Arthritis'  id='choice_1_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_3' id='label_1_23_3' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='Diabetes'  id='choice_1_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_4' id='label_1_23_4' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.5' type='checkbox'  value='Joint Replacement(s)'  id='choice_1_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_5' id='label_1_23_5' class='gform-field-label gform-field-label--type-inline'>Joint Replacement(s)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.6' type='checkbox'  value='High\/Low Blood Pressure'  id='choice_1_23_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_6' id='label_1_23_6' class='gform-field-label gform-field-label--type-inline'>High\/Low Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.7' type='checkbox'  value='Neuropathy'  id='choice_1_23_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_7' id='label_1_23_7' class='gform-field-label gform-field-label--type-inline'>Neuropathy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.8' type='checkbox'  value='Fibromyalgia'  id='choice_1_23_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_8' id='label_1_23_8' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.9' type='checkbox'  value='Stroke'  id='choice_1_23_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_9' id='label_1_23_9' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.11' type='checkbox'  value='Heart Attack'  id='choice_1_23_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_11' id='label_1_23_11' class='gform-field-label gform-field-label--type-inline'>Heart Attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.12' type='checkbox'  value='Kidney Dysfunction'  id='choice_1_23_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_12' id='label_1_23_12' class='gform-field-label gform-field-label--type-inline'>Kidney Dysfunction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.13' type='checkbox'  value='Blood Clots'  id='choice_1_23_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_13' id='label_1_23_13' class='gform-field-label gform-field-label--type-inline'>Blood Clots<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.14' type='checkbox'  value='Numbness'  id='choice_1_23_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_14' id='label_1_23_14' class='gform-field-label gform-field-label--type-inline'>Numbness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.15' type='checkbox'  value='Sprains or Strains'  id='choice_1_23_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_15' id='label_1_23_15' class='gform-field-label gform-field-label--type-inline'>Sprains or Strains<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_24\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\"><h4>MASSAGE INFORMATION<\/h4><\/div><fieldset id=\"field_1_25\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><legend class='gfield_label gform-field-label'  >Have you had a professional massage before?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_25'>\n\t\t\t<div class='gchoice gchoice_1_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_1_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_0' id='label_1_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_1_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_26\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\"><legend class='gfield_label gform-field-label'  >What type of massage are you seeking?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_26'>\n\t\t\t<div class='gchoice gchoice_1_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Relaxation'  id='choice_1_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_26_0' id='label_1_26_0' class='gform-field-label gform-field-label--type-inline'>Relaxation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Therapeutic\/Deep Tissue'  id='choice_1_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1' class='gform-field-label gform-field-label--type-inline'>Therapeutic\/Deep Tissue<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_27\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\"><label class='gfield_label gform-field-label' for='input_1_27' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_28\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\"><legend class='gfield_label gform-field-label'  >What pressure do you prefer?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_28'>\n\t\t\t<div class='gchoice gchoice_1_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Light'  id='choice_1_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_28_0' id='label_1_28_0' class='gform-field-label gform-field-label--type-inline'>Light<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Medium'  id='choice_1_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_28_1' id='label_1_28_1' class='gform-field-label gform-field-label--type-inline'>Medium<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Deep'  id='choice_1_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_28_2' id='label_1_28_2' class='gform-field-label gform-field-label--type-inline'>Deep<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_29\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\"><legend class='gfield_label gform-field-label'  >Do you have any allergies or sensitivities?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_29'>\n\t\t\t<div class='gchoice gchoice_1_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_1_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_0' id='label_1_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_1_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_30\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><label class='gfield_label gform-field-label' for='input_1_30' >Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_31\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\"><legend class='gfield_label gform-field-label'  >Are there any areas you don&#039;t want massaged?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_31'>\n\t\t\t<div class='gchoice gchoice_1_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_1_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_0' id='label_1_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_1_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_32\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\"><label class='gfield_label gform-field-label' for='input_1_32' >Please explain any conditions or areas of discomfort you have marked above:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_1_32' class='textarea large'  aria-describedby=\"gfield_description_1_32\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_32'>I have completed this form to the best of my ability, and I agree to inform my therapist if any of the above information changes:<\/div><\/div><div id=\"field_1_33\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\"><label class='gfield_label gform-field-label' for='input_1_33' >Print Name<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_1_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_34\"  class=\"gfield gfield--type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\"><label class='gfield_label gform-field-label' for='input_1_34' >Signature<\/label><div style='display:-moz-inline-stack; display: inline-block; zoom: 1; *display: inline;'><div id='input_1_34_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_1_34_valid' id='input_1_34_valid' \/><canvas id='input_1_34' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_1_35\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\"><label class='gfield_label gform-field-label' for='input_1_35' >Date<\/label><div class='ginput_container 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