Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever experienced professional bodywork before? *

Massage

Structural Integration

Craniosacral Therapy

Visceral Manipulation

Energy Healing

No

What type of pressure do you prefer? *

Light

Medium

Firm

Communication: How often do you prefer that I check in about comfort and pressure? *

Just at the beginning

Throughout the session at each body part

Other & I will share with therapist

How would you describe your general health? *

It isn't the best. I struggle often.

It is okay, but not as good as it could be.

I try to maintain good health.

I consider myself healthy.

Do you currently have any of the following health conditions? Please answer honestly, as bodywork may be contraindicated. *

Blood Clots

Infections

Congestive heart failure

Contagious diseases

Pitted edema

None

Do you have or are you at risk of high blood pressure? *

Yes

No

Are you taking any medications or supplements that may impact how you experience bodywork? *

Yes

No

Do you suffer from chronic pain or tension? *

Yes

No

Are you currently pregnant? *

Yes

No

Planning to be

Have you had any injuries or surgeries in the past that may influence today's treatment? *

Yes

No

Do you bruise easily? *

Yes

No

Are you wearing dentures? *

Yes

No

Are you wearing contact lenses? *

Yes

No

Do you identify as deaf or hard of hearing? *

Yes

No

Do you suffer from any TMJD or pain related to the jaw or mouth? *

Yes

No

In the past

Have you ever had dental procedures or surgery (teeth pulled, bridge, braces, etc)

Yes

No

Do you experience headaches or migraines? *

Yes

No

In the past

Have you ever suffered a concussion or whiplash injury? *

Yes

No

Please indicate conditions that you currently have or have had in the past *

High Blood Pressure

Muscle or Joint Pain

Orthopedic Injuries

Anxiety

Depression

Stress

Pelvic Foor Dysfuntion

Digestive Conditions

Gas, bloating, constipation

Contagious disease

Hip pain or pelvis pain

Epilepsy or seizures

Limited joint mobility

Dislocations

Numbness or tingling

Swelling

Stroke or heart attack

Varicose veins

Shortness of breath, asthma

Cancer

Neurological

Kidney disease, infection

Arthritis (rheumatoid, osteoarthritis)

Osteoporosis, degenerative spine/disk

Scoliosis

Broken bones

Sprain/strain

Endocrine/thyroid conditions

Memory loss, confusion, easily overwhelmed

Chronic or acute Lyme disease

Brain fog

Long Haul Covid

None of the above

Do you take in high amounts of any of the following?

Caffeine (4+ servings / day)

Nicotine (5+ cigarettes/vape breaks)

Alcohol (7+ drinks / week)

Fast Food (2+ times a week)

Water