Bodywork Intake Form
First & Last Name
What are your Pronouns?
Date of Birth
Emergency Contact Name & Mobile Number
What areas would you like focus on?
Any areas to avoid?
What are your goals for today's session?
What are you main physical activities? At work, when you exercise and in your free time?
When was your last bodywork treatment? What other practitioners are you working with?
CHECK IF ANY OF THE FOLLOWING APPLY
VARICOSE VEINS (NOT SPIDER)
EPILEPSY OR SEIZURES
HIGH BLOOD PRESSURE
LOW BLOOD PRESSURE
WARTS/FUNGAL INFECTION OR OTHER CONTAGIOUS SKIN ISSUES
ALLERGIES (what kind)
CANCER (what kind, past or current)
Diabetes (what type)
Have you ever broken bones? If so, where?
Accidents or injuries?
Numbness or tingling?
Please list all medications?
Are you pregnant? How many weeks?
Have you recently given birth?
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.
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.
Never submit passwords through Google Forms.
This form was created inside of sisterheartdoula.com.