CONFIDENTIAL CLIENT INTAKE

PLEASE READ!!!

This page contains important need-to-know information.

Please contact me at (307) 640-2496 or relax@transformationswellness.net if you have any questions, or any problems with this form.

If you are scheduled to receive a basic, relaxing massage service, only the first 3 parts of this online intake form are required. If you are looking for permanent correction of pain or posture problems, or if you're unsure about what you need, please fill out the entire form.

Following is a checklist to follow in the days and hours leading up to your appointment time. I recommend that you print this page as a reminder:
- Be sure to scroll all the way to the bottom of the last page to find the "Submit" button. Failure to click this button will mean that I won't receive ANY of your intake information.
- Arrive to all appointments well rested and hydrated (you can enjoy Berkey-filtered water with or without electrolytes, and herbal or green tea while you are here)
- If you have not already done so, schedule your appointment here: https://www.transformationswellness.net/schedule/
For new clients:
- Arrive 15-20 minutes early for your first appointment.
For relaxing or therapeutic massage appointments:
- No special instructions. Just wear or bring comfortable clothing to wear home after your massage.
For all other appointments:
- Wear or bring modest and loose or stretchy briefs to wear during posture assessment and treatment (I can provide tube tops for women who don't have appropriate bras - sports bras are ideal. Everyone is on their own for bottoms)
- IMPORTANT: Be sure that you have NOT taken any pain-relieving substances, including alcohol and all prescription and over-the-counter pain relievers, for at least 8 hours prior to your appointments, as these substances interfere with the natural healing process. Try to refrain from taking these substances for an additional 72 hours after treatment, if possible. (In fact, the fewer synthetic chemical you have in your body at all times, the better to facilitate your healing. One of the primary objectives of natural therapies is to reduced your need for medications.)
- Be sure that the surface of your skin is clean and dry when you arrive for your appointments, as the therapist will need to easily grip and move the skin and underlying fascia throughout the treatment. If the therapist is sliding across the skin, the treatment will be less effective.
- If you have one, please bring a 3-ring binder and page dividers with you to all your appointments, which will contain detailed reports from all previous appointments for easy reference (it's okay if you don't have this for your first appointment, but it will be helpful to have by the second time, as you'll be given a lot of articles and information right off the bat) If you don't have a binder, I will provide one to you if/when you enroll in any ongoing treatment program.
- Optional, but highly recommended: There probably won't be time to do this on your initial appointment, so plan to do this on your second visit - bring all your nutritional supplements to be tested against your meridians to determine if you're taking the right supplements and brands. This takes all the guesswork out of your investment in this aspect of your health!
- Plan to give yourself at least a 1-day break between sessions in order to allow your body time to heal and adjust to therapeutic changes.

CONFIDENTAL CLIENT INTAKE

Part 1 of 4 - Personal information (required)
Appointment Date (if you have not yet scheduled your appointment, do so here: https://www.transformationswellness.net/schedule/):

MonthDayYear
Date
Full Legal Name*

First NameMiddle NameLast Name
Preferred Nickname (how would you like me to address you?)
Biology:

I have a penisI have a vaginaI have both male and female sex organs
Date of birth:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number*
Please enter a valid phone number.
Alternate Phone Number (optional)
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact Person - name
Emergency Contact Person - relationship to you
Emergency Contact Person - phone number
Your Occupation
What do you do with your body all day long at work and/or at home? (This helps me determine where you likely carry your stress and which types of injuries you're more likely to experience.)
If you are a first-time client, who may I thank for referring you? (Where did you hear about me?)

CONFIDENTIAL CLIENT INTAKE

Part 3 of 4 - Definition of needs and type of service
What is/are the problem(s) that prompted you to schedule an appointment with me? (You may type "N/A" if you just want a relaxing massage)
How long have you been suffering from this/these problem(s)? (You may type "N/A" if you just want a relaxing massage)
What have you already tried to help yourself with your problem(s)? Which efforts have helped, which have made things worse, and which have had no effect? (You may type "N/A" if you just want a relaxing massage)
What are you hoping to get out of working with me - what are your goals for your treatment?
Comments or explanations for this section:

CONFIDENTIAL CLIENT INTAKE

Part 4 of 4 - Biofeedback & Quantum Energy Healing Demographics
Skip this section if you're scheduled for massage or Hyperbaric Oxygen Therapy (HBOT).

For all other appointment types, this section is required.
BE SURE TO CLICK "SUBMIT" AT THE BOTTOM OF THIS PAGE
The addition of Biofeedback to your manual therapy appointment allows me to gather a lot of information about what is going on with your body and your health. You'll receive a detailed Biofeedback & Treatment Report after each appointment which allows you to see how you're progressing over time, including where you're improving and where you need more work. Quantum Energy Healing is also part of your Biofeedback and manual therapy session, which means you get 2 treatments simultaneously for the price of one!

Your Biofeedback Scan will reveal to me, among other things, which of your muscles are acutely or chronically stressed. This means that I no longer need to spend 30+ minutes of your treatment time searching for the source of your problem with my hands. (Remember that the source of your problem is rarely ever in the same place where you experience the symptoms!) For you, this translates to a more efficient, effective, and longer-lasting treatment.

DETAILS ARE IMPORTANT, as they are with numerology, astrology, and biorhythm tracking. Please answer all questions fully and completely, to the best of your knowledge & ability.
Please enter your current FULL LEGAL name (full first, full middle, and full last):
Do you have a pacemaker, seizure disorder, or are you currently pregnant? (Checking "yes" disqualifies you from receiving biofeedback or quantum energy healing, but you can still receive services like manual therapy or hyperbaric oxygen. If you checked yes, you can skip the rest of this form.)

yesno
The answers to the following questions are important for customizing your biofeedback scan, in order to get accurate results. Please answer each question as accurately as you can.
Please rate your negativity (0-10):
Do you have one or more known inherited disorders?

yesno
Are you a professional athlete?

yesno
Please rate your current happiness (0-10)
How many of your organs have been removed? (ie - appendix, tonsils, ovaries, uterus, etc)
Number of synthetic drugs used currently, including over-the-counter types ("synthetic" does not include natural plant medicines or supplements. You don't need to list them, just type a number.):
Average number of cigarettes, cigars, or joints smoked daily:
Number of steroid-type drugs used in the last year:
Number of metal amalgam fillings present in your mouth during last year:
Number of street drugs used per month:
Number of all known allergies:
Number of unresolved mental factors (anger, greed, desire, sadness, fear, etc)
Rate your agreement to this statement: "I am responsible for my body" (0-10)
Average daily servings of whole plant foods in diet (unprocessed fruit, vegetables, whole grains, nuts, seeds, etc):
Percentage of fat in diet, including processed foods (average is about 30%):
Rate your personal stress (0-10):
Average number of sugar products consumed daily (includes white flour/bread products, soft drinks, ice cream, pastries, etc):
Average number of exercise sessions weekly (20-minutes or more, do not include work):
Average number of alcoholic beverages daily:
Average number of caffeinated products per day (coffee, tea, cola, chocolate, etc)
Average number of extreme toxic exposures per year (radiation, chemotherapy, insecticides, chemicals, accidental exposures, etc)
Number of major injuries in past (include surgeries and emotional trauma)
Number of major infections, past and present (Include STD's and all health- and life-threatening infections. You don't need to list them - just type a number.)
Average number of 8-ounce glasses of pure water daily:
If you consider yourself overweight, how many pounds over your ideal healthy weight are you currently? (enter "0" if not applicable, or if you are underweight. This is YOUR opinion - not your doctor's opinion.)
Birth location (city and state):
Time of birth (if known):
NOTICE:

If you have filled out this section carefully and thoroughly, AND you submit a close-up selfie of your face, I can begin running your quantum feedback scan before you arrive, which will save time and result in a more productive first visit. You can submit your selfie by e-mail to: relax@transformationswellness.net . Be sure to include your name and birth date in the e-mail so I can connect the correct image to your profile.
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CONFIDENTAL CLIENT INTAKE

CONFIDENTIAL CLIENT INTAKE

CONFIDENTIAL CLIENT INTAKE

CONFIDENTIAL CLIENT INTAKE

Skip this section if you're scheduled for massage or Hyperbaric Oxygen Therapy (HBOT).

BE SURE TO CLICK "SUBMIT" AT THE BOTTOM OF THIS PAGE

NOTICE: