Adult Inquiry Form
Please fill out the form below as thoroughly as possible. If some questions do not pertain to you, simply write: "N/A" or "NO" in the proceeding text boxes.
Name *
Your answer
Contact Phone *
Your answer
Contact Email *
Your answer
Mailing Address *
Your answer
Date of Birth *
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Occupation *
Your answer
Referred to this office by:
Your answer
Operation/Injuries *
Your answer
Purpose of this appointment *
( major complaint )
Your answer
When did these symptoms appear? *
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What makes it better or worse? *
Your answer
Is it progressively getting worse? *
How is the condition interfering with your daily routine? *
Your answer
Please explain why you would like to explore ABM. *
Your answer
Agreement and Release of Liability

It is your responsibility to inform the practitioner of any pre-existing conditions, limitations, specific sensitivities, or anything that may be relevant to your lesson. You must inform your practitioner if at any time during the lesson you feel discomfort or pain. You understand that Jon Martinez/Movement Matters does not diagnose illness, disease, or any other disorder and is NOT a substitute for medical examinations or care. You understand and voluntarily accept any risks relating to your lesson and have been allowed the opportunity to ask any questions you have relating to the inherent risks associated with your lesson. You hereby release and hold harmless Jon Martinez/Movement Matters from any and all liability of injury or harm, including without limitation, personal, bodily or mental injury, economic loss, or damage resulting from your lesson. You understand that there may be times when Jon Martinez/Movement Matters may determine that it would be unwise to proceed with or continue any lesson due to health-related concerns. I understand that this agreement and release of liability applies to this and all future lessons or dealings that I may have with Jon Martinez/Movement Matters.

Thanks,
Jon Martinez / Movement Matters
Certified ABM Practitioner

I have read and understand the foregoing statement of policy and have executed and delivered this acknowledgment as of the date indicated below: *
( Please type initials )
Your answer
Date of signature *
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