New Patient Intake
Thank you for choosing Cypris Bodywork & Wellness.  Please fill out this form to the best of your ability.
Email *
Name First & Last *
Preferred Pronouns
Home Address *
Phone Number *
What brings you in to Cypris Bodywork & Wellness Today? *
Do you have any trouble laying on your back, stomach or side? *
Do you have any sensitivities or allergies? *
If yes, please list sensitivity/allergy.  Ex.: Seasonal, Latex, Floral scents
If yes, please list sensitivity.
Do you have sensitive skin?
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Do you sit for long hours?
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Do you perform any repetitive movement in your work, sports, or hobby? If yes, please describe.
Please list your areas of concern: *
Do you have a history of cancer? *
If yes, please describe cancer type and treatments received.
Do you have a bleeding disorder or bruise easily?
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Do you have a history of inflammatory or autoimmune disease? ex. IBS, Crohn's, UC, Asthma, Rheumatoid Arthritis , Diabetes, Lupus, MS, Lyme, etc   *
If, YES, please describe inflammatory or autoimmune  disease and treatments received.
Do you have a history of cardiac disorders?  Heart Disease, High/Low Blood Pressure, etc?   *
If yes, please describe cardiac condition and treatment received.
Do you have any diagnosed mental health conditions? *
Please describe mental health condition and treatments received.
Do you have frequent headaches or migraines? *
Please describe headache/migraine triggers and treatments received.
Do you experience chronic pain? *
Please describe chronic pain and treatments received
Have you had any surgical procedures? *
Please list surgery type and date performed.
Please list any medical conditions not documented above.
Please list current medications.
I acknowledge and will adhere to the 48 hour cancelation policy of Cypris Bodywork & Wellness.  Any cancellations made less than 48 hours before agreed upon appointment time will be charge the full visit fee of $120. *
I acknowledge that my appointment starts at the time it is scheduled, and ends promptly at the agreed upon appointment duration.  No extra time is given for changing clothes, scheduling or payment. *
By entering my name in the space below I acknowledge It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.  Please type name and date signed below. *
I will participate fully as a member of my healthcare team. I will make sound choices regarding my sessions’ plan based upon the information provided by my massage therapist. I agree to participate in my own self-care programs and adhere to the plan we select. I agree to communicate with my practitioner any time I feel my well-being is being compromised. *
I understand that as part of treatment, the therapist may have contact with sensitive areas including the collar bone, front of the neck, arm pits, abdomen, sacrum, groin and inner thigh.  I agree to clearly communicate comfort level at all times. *
Out of an abundance of care and caution, Cypris Bodywork & Wellness requires both therapist and patient to wear a mask at all times, regardless of vaccination status.  This is a policy based on the population we specialize in serving, including the immunocompromised and cancer patients. I agree to comply with this mask policy.     *
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