New Client Health Screening and Liability Waiver
Please use this form to provide accurate intake information, so I know how to best provide my services. Please also make sure you have medical clearance to receive bodywork and massage services.
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Name: *
Preferred phone number: *
Email: *
Preferred contact method: *
Required
Emergency contact name: *
Emergency contact number: *
What are your reasons for therapy? *
Required
Have you received a massage or bodywork before? If yes, 1) How often, 2) Type, 3) Preferred method/style *
Describe where you have pain, discomfort, or other symptoms. *
How often do you experience your symptoms? *
Required
How would you describe the nature of your symptoms? *
Required
How are your symptoms changing? *
Required
Any possible complications or medications you are currently taking? *
What typical activities of daily living (if any) are, or have been, affected by your condition? *
What is your occupation and has it been affected by your condition? *
Do you have any worries or distress events happening in your life right now you'd like to share? *
Have you received medical clearance and/or treatment for your condition? If yes, what type of treatment  (physician, chiropractor, physical therapist, acupuncture, etc.)? *
Do you have any previous injuries that still bother you or any allergies? If yes, please describe below. *
List all surgical procedures you have had and the times you have been hospitalized. *
Is there any other info you wish to provide to aid in the success of your care? *
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