Newark Therapeutic

Newark Therapeutic

New Client Intake Form
Full Name*

First NameSurname
Address*

Street Address

Street Address Line 2

TownState / Province

Postal / Zip Code
Phone Number*
00000 000000
Email Address*
example@example.com
Your Birth Date*

DayMonthYear
Date
Where did you hear about Newark Therapeutic?: *
Have you ever had a massage or bodywork session before? If "yes" - how long ago and what type?: *
What is your occupation? *
What are your massage or bodywork goals: *
Are you...*

FemaleMaleOther
What type of therapy have you booked?*

Swedish De-stresser Massage (Medium pressure)Deep Tissue Therapy (Medium to Firm Pressure)Manual Lymphatic Drainage (Very Light Pressure)Pregnancy Massage (Light to Medium pressure)Other
If you tick "yes" to any of the following questions, please explain as clearly as possible in the comments section:*

Tick here if you like having treatment on your feet?Do you have diabetes?Do you have arthritis?Do you suffer from joint swelling?Are you pregnant?Do you have cancer?Do you have high blood pressure?Do you have varicose vain?Do you engage in regular sports or exercise?Do you suffer from epilepsy or seizures?Do you have a contagious disease?Do you have osteoporosis?Do you have fibromyalgia?Do you bruise easily?Have you had any broken bones in the last two years?Have you had any injuries in the last two years?Do you have tension or soreness in a specific area? If "yes" please give more details below.Do you have any cardiac or circulatory problems?Do you have swelling in a particular area? If "yes" please give more details below.Do you suffer from back pain? If "yes" specify belowDo you have numbness or stabbing pains?Are you sensitive to touch or pressure in any area?Have you ever had any surgery I should know about?Any other medical conditions or taking any medications I should know about?Do you have acute deep vain thrombosis?Do you frequently suffer from stress?Do you have frequent headaches?
Comments:
Are you currently taking any medication?

YesNo
Please list them
Do you have any allergies?

YesNoNot Sure
Please list them
I understand that:

1.This bodywork session is provided for the purpose of relaxation and relief of muscle tension and or relief form minor aches and pains, to aid in circulation and or in the case of MLD to aid in the efficiency and health of the lymphatic system.
2.One treatment/session alone is often not enough to completely fix many complex issues.
3. If I feel unbearable discomfort, I will inform the therapist immediately so that they may adjust the work being performed.
4. Massage or bodywork should not be confused with medical examination, diagnosis or treatment.
5. Because massage or bodywork should not be performed under certain medical conditions, I confirm that I have stated all my known medical conditions and answered all questions honestly.
6. I agree to keep the practitioner updated as to any changes in my medical profile and understand the practitioner shall not be held liable if I fail to do so.
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