Bodywork Intake formPlease fill out this form to the best of your ability prior to your appointment! Name * First Name Last Name Date of your appointment * MM DD YYYY Email * Would you like to be added to our email list to receive future updates, promotions, discounts, and details about community events? * Yes, please! No thanks! How did you hear about us? * What is your gender and what are your preferred pronouns? * What is your occupation? * What is your date of birth? * Is this a mobile session or an office session? * Mobile Office Address If this is a mobile session where is the address that it will be held? Address 1 Address 2 City State/Province Zip/Postal Code Country Do you have any skin sensitivities of scent sensitivities of any kind? If so, please specify. * What is your pressure preference? * Are you currently contagious with anything that might impact a bodywork session? * Are there any areas that you would like to have be AVOIDED during your bodywork session? If so, please specify. * Please tell me a title bit about any specific body concerns you may have: (describe the concern(s), when did it start, is it constant or does it come and go, what helps it, what aggravates it, was there a specific incident which caused it, Pain – type, intensity, frequency, etc.) * Please check any area in the checkboxes below that might apply to you currently or in the past: * Bruise Easily Joint Issues Thyroid Issues Vertigo Multiple Sclerosis Seizures Hospitalized Concussions/Head Trauma Major Dental Work Orthodontics Heart Attack Allergies Menopause Cancer Smoker Diabetic Inflammation Contact Lenses High/Low Blood Pressue Fatigue Sleep Issues Osteoporosis Dentures Pacemaker Hormone Imbalance Touch Sensitive Deep Vein Thrombosis Medication Varicose Veins Blood Clots Edema Substance Challenge Use Of Herbal Medicine/Supplements/Vitamins Asthma Headaches Or Migranes Atherosclerosis Autoimmune Disorders Boundary Issues Worry Fear Anger Depression Stress Grief Anxiety None Please describe any of the areas that you have checked above that apply to the PAST or PRESENT. Please provide dates if possible. * Are you currently under the care of a healthcare practitioner? If so, for what condition? Are you currently pregnant? Yes No If yes, how many weeks? If postpartum, how many months? Are you experiencing/have you experienced any complications in your pregnancy? If yes, please describe. Please list the number of pregnancies that you have had in the past, and the delivery types of each. Have you had any recent life changes ? If yes, please describe. * How would you best describe your current lifestyle? * Is there anything else about your health history that you think would be helpful for your bodywork practitioner to know to plan a safe and effective treatment for you? * Thank you so much for taking the time to fill out these forms! This information will be used to accurately create a treatment plan that is best suited to your needs!We look forward to working with you!
