Alissa Dann CMT-HE, SRT, NKT
Filling out this one time intake form as much as possible, history wise, in advance allows me to prepare better options for your sessions. Thank you! Questions: Call or Text 24/7: 707-536-1147 - empoweredlivingabt@att.net
IMPORTANT NOTE:
If you don't have time to fill out this form in one setting, go to the bottom of this form and click SAVE. Click "skip create account", insert your email, and you will get the part of the form that you have filled out emailed to you. Then click on the link through email, to fill out more later. If you don't follow these instructions, there is a risk what you have filled out already, may be lost. Thank you.
Full Legal Name:
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Nickname(s)/Name you go by:
Today's Date:
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone:
Home Phone:
E-mail
example@example.com
Birth Date
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Year
Emergency Contact:
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Emergency Contact Phone:
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Height:
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Weight:
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Age:
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Gender:
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Are you currently pregnant, or plan on getting pregnant?
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Yes I am Pregnant
No I am not Pregnant
I plan on getting Pregnant
N/A
How/from whom did you hear about us?
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Would you like to be included in the occasional email list to hear of updates, information, etc.?
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Yes
No
What Modalities Are you most Interested in Receiving?
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Any and All Modalities
Spinal Flow Technique
Massage Cupping Therapy
Craniosacral Therapy
Visceral Manipulation
Advanced Neurological Osteopathic Modalities
What are your feelings on Session Process/Results?
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I want to book ahead to move through programs or at least come monthly
I want to come in every so often/maintenance
Whenever I feel I need sessions
Just this one time
I am a person/practitioner looking to experience Spinal Flow in person before enrolling in the Spinal Flow Technique Certification through Dr. Carli Axford.
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Yes
No
Medications, ex. pain reliever
Optional Medication list upload:
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Choose a file
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Vitamins and Supplements you are currently taking:
List all allergies including Metals, Scents, Food, Medications, Seasonal etc.
Date of Injury/Accident(s):
Information/Areas of Pain/Details:
Diagnosis Given for Issue right now:
Check all you have consulted for your symptoms:
Physician
Naturopath
Neurologist
Orthopedist
Psychologist
MD
DO
DC
Psychiatrist
Counselor
Physical Therapist
Occupational Therapist
Massage Therapist
Acupuncturist
Biofeedback
Other Consults (Specify):
List Past Surgeries and Dates:
Please check any of the items that apply to you:
Right-Handed
Left-Handed
Both
What are you hoping to gain from these session(s)?
Relaxation/Maintenance
Accident/Injury Relief
Headache Relief
Pre Surgery Options
Post Surgery Options
Chronic Condition(s) Anything else you experience, or are experiencing right now? (Specify):
What is your CURRENT occupation (Not employer):
List Previous Occupation(s) (to assess types of positions you tend to move in ex. Plumber, Construction, Hairstylist, Desk Job, etc.):
What kinds of activities RELIEVE or DECREASE your symptoms:
What kinds of activities INCREASE your symptoms:
Describe the PATTERN of your symptoms or: shooting, stabbing, referring etc.:
Check any other symptoms you are experiencing:
Anxiety
Allergies
Dizziness
Stiffness
Nausea
Headaches
Diarrhea
Constipation
Weight Loss
Weight Gain
Depression
Shooting Pains
Clenching Teeth
Tiredness/Fatigue
Sexual Dysfunction
Shortness of Breath
Sleep Changes +
Sleep Changes -
Pounding/Racing Heart
Limited Movement
Other Symptoms (Specify):
Any other injuries/accidents you have been involved in over the years (Birth through Present):
If headaches/migranes are a main concern, Check all that apply:
Headaches N/A
How often do you get headaches?
Daily
Every Other Day
Once a Week
Once a Month
Twice a Month
Sporadically
Rarely
How long do your headaches last?
Hours
One Day
Two Days
Three Days
Four Days
Longer than four days
They never go away
Where in your body do you FIRST feel your headache?
Forehead
Neck
Jaw
Behind your eyes
Behind one eye
Ear (Right or Left)
Middle Back
Upper Back
Shoulders
Other Information (Specify):
How would you DESCRIBE your headache?
A vice around your head
Forehead Pressure
Earache
Pressure from inside moving out
Pressure pushing on Left or Right side of face
Bright lights followed by extreme pain
Other (Specify):
What time of day do you FIRST notice your headache?
Upon first waking
Just after getting out of bed
Mid Morning
Noon
Early Afternoon
Late Afternoon
Early Evening
Late Evening
Other (Specify):
Check all physical symptoms that you have been or are currently being treated for:
Skin Conditions:
Eczema
Cancer
Herpes
Psoriasis
Athelete's Foot
Ring Worm
Acne
Burns
Other Skin Conditions (Specify):
Respiratory Conditions:
Asthma
Bronchitus
Collapsed Lung
Chest Pain
Lung Disease
Pneumonia
Pulmonary Embolus
Tuberculosis
Covid-19
Other Respiratory Conditions (Specify):
Nervous System Contitions:
Multiple Sclerosis
Sciatica
Neuroma
Neuritis/Neuropathy
Neuralgia
Pinched Nerve
Numbness/Loss of Sensation
Bulging Disk
Ruptured Disk
Other Nervous System Conditions (Specify):
Circulatory Conditions:
Phlebitis
Blood Clots
Vericosities
High Blood Pressure
Low Blood Pressure
Heart Disease
Pace Maker
Angina
Stroke
High Cholesterol
Irregular Heart Beat
Bruise Easily
Other Circulatory Conditions (Specify):
Digestive/Urinary Conditions:
Ulcer
Colitis/Chron's Disease
Irritable Bowel
Gall Bladder/Stones
Kidney Infection/Stones
Bladder Infection
Nephropathy
Chronic Renal Failure
Liver Disorder/Disease
Chronic Constipation
Chronic Diarrhea
Acid Reflux
Gas/Bloating
Other Digestive/Urinary Conditions (Specify):
Muscle/Tendon Conditions:
Sprain
Strain
Tendonitis
Bursitis
Fibromyalgia
Chronic Stiffness/Leg/Foot Cramps
Muscle Weakness
Limited Movement
Carpal Tunnel
Tennis Elbow
Plantar Fasciitis
Other Muscle/Tendon Conditions (Specify):
Osteopathic Conditions:
Broken Bones
Osteoporosis
Degenerative Hip
Degenerative Shoulder
Degenerative Knee
Joint Replacement - Hip
Joint Replacement - Knee
Joint Replacement - Shoulder
Other Osteopathic Conditions (Specify):
Lymphatic Conditions
Chronic Colds
Chronic Flu
Allergies
Headaches/Migraines
Cellulite
Edema
Swelling
Other Lymphatic Conditions (Specify):
Other Conditions/Symptoms:
Post Polio
Cancer
Anemia
Stroke
Asthma
Diabetes (Type 1)
Dibetes (Type 2)
Menstrual Cramps
Ovarian Cancer
Vertigo
HIV+
AIDS
PMS
TMJ
Gout
Alcoholism
Emphesema
Lupis
Endometriosis
Cervical Cancer
Fibrocystic Breasts
Rheumatoid Arthritis
High Thyroid
Low Thyroid
Chronic Sinus Infections
Dizziness or Fainting spells
Breast Cancer
Perimenopausal Symptoms
Post menopausal Symptoms
Ovarian Cysts
Ringing in ears/Tinnitis
Anything else you would like to tell me about? (Specify):
Please Initial Each Line and Sign at the Bottom:
I am aware that this is a non sexual massage. Any form of misconduct or inappropriate behavior will immediately terminate the session with full payment due.
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I understand that almost all therapies in this practice are done clothed in loose layers of clothing. If I need to disrobe partially the therapist will discuss any draping procedures with me prior to that part of the session, if that is an area in which I need or ask for.
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I understand that the therapist does not diagnose, prescribe, or treat any illness, ailment, or disease. I understand that the therapist does not "fix" me. I understand that even though my symptoms or ailments may be "gone" after treatments, I still need to talk to my doctor and should never stop my medication without talking to my doctor first. I also understand that the therapist may assist at my discretion in relief of physical or emotional symptoms that could occur during the session as traumas are held in the body and could be released.
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I understand that this Spinal Flow Technique, Neurokinetic Therapy, Structural Relief Therapy, Neural Reset Therapy, CranioSacral Therapy, Visceral Manipulation, Massage Cupping Therapy, Zoom, Conference Calls, or In-Person Classes/Workshops, Retreats and all other treatments done by this therapist includes but is not limited to, stress reduction, relaxation, breaking up of fascia and scar tissue, and relief of muscular tension or spasm, and is not a substitute for medical treatments, or exams.
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I understand that I need to let my therapist know of any medical changes in my health and that I may need to get written permission from my doctor, for my therapist to proceed with Session Treatments.
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I understand that at least 24 hour notice of cancellation is required: otherwise I will be liable to pay 50% for either a late cancellation or missed appointment that could have been filled by others.
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I agree to pay Venmo, Cash/Check/PayPal, Debit/Credit before, or after the session. If my check bounces, I agree a $20.00 service fee, as well as any additional fines the therapist may incur as a result.
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By signing below I affirm that all I have said is accurate, I am who I say I am, and I affirm that everything I have imput into this form is completely true. I understand that this form will remain confidential to the extent of the law.
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Client Signature:
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Signature
Today's Date:
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Parent/Guardian Signature (If client is under the age of 18)(NOTE: Parent/Guardian is required to attend and at least sit out in the waiting room):
Today's Date:
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Alissa Dann CMT-HE, SRT, NKT - 707-536-1147 - 1301 Farmers Lane Suite 302 Santa Rosa, CA 95405
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