Client Intake Form

A little about you, before we begin.

Name

First Name

Last Name

Phone

(###)

###

####

Emergancy contact / Name and Number

Occupation

Referred by

Have you had any complementary therapy treatments before?

yes

Please elaborate if yes.

Are you currently under a physician’s or other specialist’s care?

yes

Please elaborate if yes. Name and detail of physician.

Mental & Emotional

Migraines/Headaches, Poor Memory/Concentration/Recall, High Stress, Overwhelmed Easily, Panic Attacks, Self doubt, Lack motivation, Fatigue, Depression, Mood swings, Excess Worry, Anxiety, Suicidal thoughts, Anorexia/Bulimia Other? Please describe:

Nervous System

Dizziness, Nervousness, Tingling/Pins & Needles, Numbness, Shooting Pains, Restless Legs, Low/Erratic Energy Levels, Over stimulated, Trouble sleeping, Other? Please describe

Circulatory System

Anemia, Angina, Hemophilia, Heart issues, Stroke, High/Low Blood pressure, High/Low Cholesterol Other? Please describe

Gastrointestinal System

Bloating, gas, Heartburn, Indigestion, Pain, Distension, Excess/Loss of Appetite, Fullness after meals, Constipation, Diarrhea, Intolerance of Fatty Foods, Mucus/Blood/Pale/ Black Stools, Anal Itching, Hemorrhoids , Cravings, Bad Breath, Waking between 1-3am, Sluggish Heavy Feeling Other? Please describe:

Musculoskeletal System

Sore neck and shoulders, Stiffness, Cramps, Sprains, Injuries, Arthritis, Carpal Tunnel Syndrome, Disc or spinal issues, Sciatica, Fibromyalgia, Teeth Grinding, Locked Jaw (TMJ), Repetitive Strain Injuries (RSI) Other? Please describe:

Immune System

Frequent Colds/Infections, Slow Healing, Cold Sores, Sore Tongue, Swollen Lymph Glands, Food or Environmental Allergies/Intolerance, Fevers, Viruses Immune Disorders Other? Please Describe:

Reproductive System

Menstrual Cycle Irregularities, PMS/PMDD, High/Low Blood Flow, Hot Flushes, Pain on Intercourse, Tender/Swollen/Painful/Lump in Breasts, OCP, IUD, Cysts, Fibroids, Miscarriage/ Fertility issues, Low/Excess Libido Other? Please describe:

Other

Please note anything of importance that we may have missed.

CLIENT CONSENT / WAVIER - Fill in Name to agree

I verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety purposes and will be kept strictly confidential, unless I provide written consent. I hereby give my consent to receive treatments and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such services are my sole responsibility. My decision to receive services is voluntary, and I know of, understand and assume any and all the risks associated therewith. In exchange for receiving services for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold my therapist harmless from any and all liability for any and all injuries, including damages or claims relating to or resulting from my receipt of the services, now or in the future, foreseen or unforeseen. Please take a moment to read and initial the following information: • If I experience pain or discomfort during the session, I will immediately inform my therapist. I will not hold my therapist responsible for any pain or discomfort I experience before, during or after the session. • I understand that the services offered today are not a substitute for medical care. • I understand that my therapist is not qualified to carry out a medical examination or provide a diagnosis and I agree not to interpret their comments as medical advice. • I affirm that I have notified my therapist of all known medical conditions and injuries. • I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. • I understand my medical information and treatment notes may be released to other, third party, health practitioners whom I agree for my therapist to refer me to. • I agree that my therapist will need to disclose my personal information, if required to by law. • By signing this release, I hereby waive and release my therapist from any and all liability, past, present and future relating to this treatment.