forms printable forms ; Client Waiver Form ; New Client Intake Form Client waiver form Name* First Last Email* Terms*I understand that fascial stretch/massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation, range of motion and energy flow. Agree Terms*If I experience pain or discomfort during the session, I will immediately inform my practitioner so that pressure can be adjusted to my level of comfort. I will not hold my practitioner responsible for any pain or discomfort experienced during or after the session. Agree Terms*I affirm that I have notified my practitioner of any changes in my health and medical condition. I understand that there shall be no liability on the instructor(s) part should I forget to do so. Agree Terms*I understand that stretch/massage therapy sessions are designed to assist in greater stretch gains and are non-sexual in nature. Agree Terms*I understand that there is a 24-hour cancellation policy. If I am unable to cancel before that time I will be responsible for the costs associated with that session. Agree Terms*I agree that this is a cash only business and insurance will not be accepted. Health Savings Accounts are accepted, however client is responsible for obtaining documentation. Agree Terms*I understand the services offered today are not a substitute for medical care. I understand that my practitioner is not qualified to perform spinal or skeletal adjustments,diagnose, prescribe, or treat physical or mental illness. Agree Sign Name*By signing this release (typing my name below), I hereby waive and release my practitioner from any and all liability,past, present and future relating to these fascial stretch/massage sessions/bodywork. I have read and agree to these policies therein. First Last Date*Today's Date MM slash DD slash YYYY New Client Intake Form Name* First Last Date of Birth* MM slash DD slash YYYY Email* Phone Number*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Referred By First Last General Information What is your main reason for coming to therapy? How and when did your symptoms begin? Where are your symptoms located? List all that apply. Face Throat Breast Chest Outer Arm Rib Cage Stomach Forearm Top Thigh Inner Thigh Knee Shin Ankle Head and Neck Upper Shoulder Shoulder Spine Inner Arm Elbow Low Back Inner Forearm Buttocks Hand and Wrist Inner Thigh Back of Knee Calves Feet Other Are your currently, or have your ever been, under medical supervision for this problem? Have you had any tests for this problem, such as x-rays, MRI or CT scans? Describe the symptoms. Please check all that apply: Dull Ache Burning Sharp Periodic Constant Sore Stiff Numb Tingling Other Is there anything that makes it better or worse? On a scale of 1-10, with 10 being the most severe imaginable discomfort, what is your level of discomfort right now?Please enter a number from 1 to 10.What time of day is the pain worst? Do you have trouble sleeping? If yes, what position do you sleep in? Physical Factors What physical activities are you currently involved in? Do you stretch now? Yes No Do you feel flexibility is an important part of fitness? Yes No Do you feel flexibility is an important part of fitness? Yes No Have you ever had chiropractic or Naturopathic treatment? If yes, how long, how often, and with whom? Have you experienced any kind of bodywork before (i.e. massage, acupuncture, etc.)? If yes, what type? Massage Stretch Therapy Acupuncture Dry Needling Other Do you wear any type of supportive braces or orthotics? Yes No What percentage of your day is spent sitting? What percentage of your day is spent standing? What percentage of your day is spent driving? Are your symptoms worse at the end of the workday? Yes No Does your work station give you support and encourage good posture? Yes No How would you rate your own posture?Please enter a number from 1 to 5. Medical History Please list any recent injuries, illnesses, or surgeries: Are you currently under the care of a physician? Yes No If yes, please explain:List any current medications, including aspirin, ibuprofen, etc.Please check all that apply to you Cancer Digestive Problems Migraines/Headaches Back Problems Sciatica Stroke Scoliosis Osteoporosis Diabetes Hi Blood Pressure Low Blood Pressure Constipation Diarrhea Respiratory Problems Sinus Problems Neck Problems Arthritis/Bursitis Immune Disorder TMJ Immovable Joints Epilepsy Ulcers Cold Hands/Feet Heart Problems Bruise Easily Allergies Fibromyalgia Carpel Tunnel Asthma Other Do you have any chronic or frequent pain? Have you had any accidents, auto or other? Have you ever had any major surgeries? Have you ever had a head injury? If yes, have you noticed the following? (check all that apply): Dizziness Change in Vision Change in Hearing Other Are there any other medical conditions the therapist should be aware of?Are you pregnant? Yes No Unsure If yes, how many weeks? The above information is accurate and true to the best of my knowledge. If there are any changes in my current level of health, I will inform the person that I am seeing of my condition. I understand that this office does not diagnose or treat illness or disease and does not prescribe medications. I agree to pay my account with this office in accordance with the regular rates and payment terms. If, for any reason, cancellation is necessary, I will give a 24-hour notice. I understand that if I do not give this notice, I will be charged for the appointment unless it can be filled. Owner will determine emergency cancellations. It is agreed that any claim of liability is hereby waived. Sign Name*By signing this release (typing my name below), I hereby waive and release my practitioner from any and all liability,past, present and future relating to these fascial stretch/massage sessions/bodywork. I have read and agree to these policies therein. First Last Today's Date* MM slash DD slash YYYY
