PostureWorks

Intake Form

Please fill out the following form before your first visit to PostureWorks.

First Name

Email Address

Cell Phone

Last Name

Birthday

Address

Employer

Occupation

Emergency Contact

Physician Name and Phone

Reason for initial visit

Circulatory Health

Heart condition

varicose veins

Blood Clots

High/low Blood Pressure

Digestive Health

Irritable bowel

Crohn's Disease

Ulcers

Bladder/Kidney Ailment

Respiratory Health

Asthma

Emphysema

Allergies

Sinus Problems

Reproductive Health

Pregnancy

PCOS

Menstrual Problems

Prostate

If you are pregnant how many weeks are you?

If Pregnant are you experiencing any of the following medical conditions?

Have you been hospitalized in the last 12 months?

Yes

Client Agreement:

It is my choice to receive treatment. I am aware of the benefits and risks of massage and exercise and give my consent for massage, stretching, yoga, or personal training. 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, stretching, yoga, or personal training 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. By signing this waiver, I hereby release Leah Klein, insurers, and indedpendent contractors working at PostureWorks, PLLC. from liability past, present, and future relating to bodywork, stretching, and massage therapy.

I declare that the info I’ve provided is accurate & complete and I consent to the above Client Agreement.

Your Signature

Today's Date

Pregnancy Massage Only:

I understand there are possible contraindications to massage therapy during pregancy. In addition, I have discussed this with my physician and have had the opportunity to ask questions of the massage therapist and of my physician about the information.

I understand the information and confirm that:

I have not experienced any of the complications listed above.

I have not experienced and of the conditions listed which would make it unwise to have massage therapy.

I am experiencing a low risk pregnancy.

I am receiving medical care including regular check-ups throught my pregnancy.

I understand that I will be receiving massage therapy as a form of adjunctive health care only and that this therapy is not inteded to replace appropriate medical care.

I do forever release PostureWorks Clinical Massage and Stretch Therapy, it' massage therapists, insurers, and all independent contractors working at PostureWorks from all liabiliity of any nature whatsoever, whether past, present, or future for injury or damage which may occur to myself or my family as a result of my receiving massage therapy during this childbearing year.

I agree to hold harmless and defend the practicioner of and from all actions, claims, or other legal or administative action that has arisen or may arise directly from me and my child.

I accept terms & conditions

Your Signature

Today's Date

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