Client Intake Form Client Intake Form Step 1 of 4 25% URLThis field is for validation purposes and should be left unchanged.Client InformationName(Required) First Last Date of Birth(Required) Email(Required) Mobile Phone(Required)Work Phone(Required)Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code OccupationEmployerMarital StatusSingleMarriedIf Married Spouses Name Emergency InformationEmergency Contact NameRelationshipEmergency Contact PhonePhysician's NamePhysician's PhoneTreatment HistoryHave you had a professional massage? Yes No What type of massage have you experienced?Have you had physical therapy? Yes No Was physical therapy helpful? Yes No Health InformationPlease check all that applyMusculoskeletel Bone or Joint Disease Tendinitis/Bursitis Arthritis/Gout Jaw Pain (TMJ) Migraines/Headaches Osteoporosis Plantar Fasciitis Skin Allergies Rashes Cosmetic Surgery Athlete’s Foot Eczema Psoriasis Circulatory Heart Condition Phlebitis/Varicose Veins Blood Clots High/Low Blood Pressure Lymphedema Thrombosis/Embolism Psychological Anxiety/Stress Depression Other Other PsychologicalDental History Braces Dentures Extractions Oral Surgery Missing Teeth Number of Missing TeethVision Contact Lenses Glasses Astigmatism Respiratory Breathing Difficulty/Asthma Emphysema Sinus Problems Nervous System Shingles Numbness/Tingling Pinched Nerve Paralysis Multiple Sclerosis Parkinson’s Disease Prior Stroke or Brain Injury Reproductive Pregnant Cesarean Section Child Birth StageNumber of ChildrenDigestive Irritable Bowel Syndrome Bladder or Kidney problem Colitis Crohn’s Disease Ulcers Other Cancer/Tumors Diabetes Drug/Alcohol Use Smoke or Vape Hearing Aids Other Medical ConditionsPlease explain any other medical conditions, surgeries, or prior injuries including childhood: MarketingHow did you hear about us? Referral Online Ad Referred by:Consent to treatIt is my choice to receive Postural Restoration, massage, bodywork and breath coaching. I am aware of the benefits and the risks associated with massage and body work and give my consent for treatment. I acknowledge to the best of my ability that I have reported all medical conditions and that I am aware of and will report any change in my health status. I understand that Postural Restoration and the associated activities are not physical therapy or a medical diagnosis. A typed name shall serve as an electronic signature and carry the same force and effect as a handwritten signature.Full Name(Required)Date(Required) Cancelation AgreementI understand that scheduled appointments are valuable time to me as the client, to the therapist, but most importantly to other clients who would benefit from limited appointment times. I will notify the therapist within 24 hours if an appointment needs to be rescheduled or cancelled. Failure to give proper notice may require full payment for the missed session. Three (3) violations of the cancelation policy will result in an inability to schedule future appointments, and treatment will need to be sought elsewhere. A typed name shall serve as an electronic signature and carry the same force and effect as a handwritten signature.Full Name(Required)Date(Required)
