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Comprehensive Bodywork Intake

SECTION 1 - CLIENT INFORMATION

Birthday
Month
Day
Year

SECTION 2 - GENERAL HEALTH HISTORY

How would you rate your overall health?
Excellent
Good
Fair
Poor
Are you currently under medical care?
Yes
No

SECTION 3 - MEDICAL CONDITIONS

Please select all that apply;

SECTION 4 - ALLERGIES & SENSITIVITIES

Do you have any allergies?

SECTION 5 - PREGNANCY

Are you currently pregnant?
Yes
No
Trying to conceive
Unsure

SETION 6 - MEDICATIONS AND SUPPLEMENTS

SETION 7 - YOUR APPOINTMENT

How would you describe the sensation?

SECTION 8 - FUNCTIONAL HISTORY

Are you physically active?
Recent intense training in last 7 days?
Yes
No

SECTION 9 - STRESS & NERVOUS SYSTEM

Do you feel your pain is connected to:
Sleep quality
Restful
Interrupted
Poor

SECTION 10 - PRESSURE & CONSENT

Pressure preference:
Light
Moderate
Firm
Please adjust as needed
Are you comfortable with topical magnesium for muscle support?
Yes
No

SECTION 11 - INFORMED CONSENT

Professional Boundaries

Massage and bodywork provided are strcitly therapeutic in nature. Any inappropriate language, behavior, or requests will result in immediate termination of the session without reimbursement.

Insurance & Receipts

At this time, services are not eligible for extended health insurance reimbursement. Receipts can be provided for personal records.

Informed Consent

I understand that bodywork is not a substitute for medical care and no diagnosis is provided. I confirm that I have disclosed all relevant health information. I understand that I may withdraw consent at any time. I agree to inform the practitioner of any changes in my health status. I understand that therapeutic bodywork involves manual techniques that may include deep pressure, stretching, and movement-based assessment. I acknowledge that mild soreness, temporary discomfort, or emotional release may occur. I voluntarily consent to treatment and understand that results are not guaranteed.

Date
Month
Day
Year
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