Intake Form for Lee Brewster, HSE

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Email *

First Name *

Last Name *

Best phone number to reach you (include area code) *

Street Address *

City *

State *

Zip *

Do you have pain?

Yes

If you have pain, where is your pain located?

If you have pain, what treatments, diagnoses, x-rays have you received regarding your pain?

History of surgeries and illnesses:

History of falls (concussions) and fractures:

What are you hoping to gain from this session?

What do you do for work?

What do you like to do in your free time?

Waiver of LiabilityI UNDERSTAND THE ACTIVITY I AM PLANNING TO UNDERTAKE IS ENTIRELY VOLUNTARY. I RELEASE HANNA SOMATIC EDUCATOR PRUDENCE LEE BREWSTER FROM ANY LIABILITY IN EVENT OF AN INJURY. I KNOW THAT I HAVE THE RIGHT TO CHOOSE WHAT EXERCISES I DO AND DO NOT PREFORM IN ADDITION TO WITHDRAWING FROM ANY EXERCISE AT ANYTIME. I UNDERSTAND IT IS SOLEY MY RESPONSIBILITY TO DISCLOSE ANY PRIOR EXSISTING HEALTH CONDITIONS. THE POSSIBILITY OF CERTAIN UNUSUAL CHANGES DURING EXERCISE DOES EXSIST THEY INCLUDE MUSCLE SORENESS OR STIFFNESS, ABNORMAL BLOOD PRESSURE, FAINTING, DISORDERS OF THE HEART, AND INSTANCES OF HEART ATTACK AND DEATH. EVERY EFFORT WILL BE MADE TO MINIMIZE THEM BY OFFERING MODIFICATIONS TO EXERCISES. TO MY KNOWLEDGE I DO NOT HAVE ANY LIMITING PHYSICAL CONDITION OR DISABILITY THAT WOULD PRECLUDE AN EXERCISE PROGRAM. IT IS MY RESPONSIBILITY TO DISCUSS THIS WITH MY PHYSICIAN. *

By checking here I have signed the waiver of liability

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