Energy Yoga - Therapy Intake Form
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Email *
Full Name *
Phone Number *
Address *
City, State & Zip Code *
Occupation
Employer
Primary Care Physician / Phone
How did you hear about us?
Is the reason you are visiting today in any way related to a lawsuit for an accident? *
Please list any medications you are currently taking? *
Are you pregnant? *
If you are pregnant how far along are you?
If pregnant do you have any high risk factors?
Do you suffer from chronic pain?
If you suffer from chronic pain, what makes it feel better?
If you suffer from chronic pain, what makes it feel worse?
Please list any orthopedic injuries or surgeries:
Please indicate any of the following that apply to you: *
Required
What type of massage are seeking? (Include as many as you would like to experience) *
Required
What pressure do you prefer? *
Do you have any allergies or sensitivities?
Are there any areas (feet, face, abdomen, etc.) of the body you would not want massaged?
What are the goals of your treatment today? *
Please list any areas of the body where you experiencing discomfort and would like to focus on in your treatment today? *
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