New Client Intake Form
Please complete the New Client Intake Form prior to the start of your appointment. This will help me get a better idea of what issues you're experiencing and will help me to determine a path for our treatment plan. I can't wait to start working with you! See you soon!
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?
Do you have a physician referral/prescription?
Have you ever received professional massage/bodywork before?
What kind of pressure do you prefer?
Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?
List the medications you currently take:
Select any of the following health conditions that you currently have (If you are unsure, please ask. Please answer honestly, as massage may not be indicated for the above conditions):
Please answer the following questions and indicate conditions that you have or have had in the past. Muscle or joint pain
Muscle or joint stiffness
Sensitive to touch/pressure
Shortness of breath, asthma
Neurological (e.g. MS, Parkinson’s, chronic pain)
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn’s, IBS), bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Endocrine/thyroid conditions
Memory Loss, confusion, easily overwhelmed
Please use this box to elaborate further on any issues or conditions you may have that you feel is relevant information to your bodywork session:
I acknowledge that I have reviewed the Cancellation Policy outlined in the FAQ section of the website and will adhere to said policy outlined by the company, Good Vibes Bodywork.*
I acknowledge that I have reviewed the Sickness/Emergency/Weather Policy outlined in the FAQ section of the website and will adhere to said policy outlined by the company, Good Vibes Bodywork.*
I acknowledge that I have reviewed the Payment/Insurance Policy outlined in the FAQ section of the website and will adhere to said policy outlined by the company, Good Vibes Bodywork.*
I acknowledge that I have reviewed the Inappropriate Behavior Policy outlined in the FAQ section of the website and will adhere to said policy outlined by the company, Good Vibes Bodywork.*