Bodywork Intake Form
Email address *
CONTACT INFO
First & Last Name
Your answer
What are your Pronouns?
Date of Birth
MM
/
DD
/
YYYY
Street Address
Your answer
Email Address
Your answer
Mobile Number
Your answer
Occupation
Your answer
Emergency Contact Name & Mobile Number
Your answer
Referred By
Your answer
HEALTH DETAILS
What areas would you like focus on?
Your answer
Any areas to avoid?
Your answer
What are your goals for today's session?
Your answer
What are you main physical activities? At work, when you exercise and in your free time?
Your answer
When was your last bodywork treatment? What other practitioners are you working with?
Your answer
CHECK IF ANY OF THE FOLLOWING APPLY
ALLERGIES (what kind)
Your answer
CANCER (what kind, past or current)
Your answer
Diabetes (what type)
Your answer
Autoimmune disorder
Your answer
Digestion issues
Your answer
Have you ever broken bones? If so, where?
Your answer
Surgeries?
Your answer
Accidents or injuries?
Your answer
Numbness or tingling?
Your answer
Other?
Your answer
Please list all medications?
Your answer
WOMEN'S HEALTH
Menstrual pain/disorders?
Your answer
Are you pregnant? How many weeks?
Your answer
Have you recently given birth?
Your answer
Menopause?
Your answer
AGREEMENTS *
I understand that the bodywork session that I receive from Marta Dwaihy is provided for the basic purpose of relaxation, stress reduction, and relief of muscular tension. I further understand that bodywork should not be construed as a substitute for medical examination, diagnosis or treatment and that any mental or physical ailment or condition that I am aware of, I should see a physician, chiropractor or other qualified medical specialist. I also understand that Marta does not diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such.I affirm that I have stated all my known medical conditions, and answered all questions on this form and/or asked by the therapist, honestly and completely to the best of my knowledge. I agree to keep Marta updated in future sessions to any changes in my medical profile. I also agree there is no liability on Marta’s part should I fail to do so.If I experience any pain or discomfort during this and any future sessions, I will immediately inform Marta so the techniques may be adjusted to my comfort level.
NO FRAGRANCE POLICY *
I will not wear synthetic fragrances including: perfumes/cologne, scented lotions, hair spray/products, deodorant/antiperspirant, fabric softener to any future sessions.
CANCELLATION POLICY *
If I do not give at least 24 hours cancellation notice for any future appointments, I will be liable for the full fee of the session missed.
By clicking "I ACCEPT" for the above policies you are signing electronically
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of sisterheartdoula.com. Report Abuse