Body & Soul Online Intake Form

Get Ready to Transform Your Health!

Get Ready to Transform Your Health! In order to get the best results out of you therapy session, answer the questions below as best you can. We will discuss in further detail during your session TIPS to ENHANCE YOUR THERAPY Refrain from using any lotions or oils; wear loose fitting shorts/sports bra. Myofascial release is performed directly on the skin so it is best to wear clothing that is loose fitting in order for the therapist to access different areas of the body.

Once I receive this completed form from you, we can book in our first session and can get to work. If you have any questions, just ask: michelle@expertmyofascialrelease.com or Patricia bodyandsoulusa@gmail.com
1. Email *
example@example.com
2. Full Name *
3. Mailing Address *
4. City *
5. State *
6. Zip Code *
7. Phone Number *
8. Date of Birth *

Month Day Year
Date
9. What is the main reason for your session today? *

Pain Relief Self Treatment Instruction Relaxation Other:
10. Height *
11. Occupation . *
12. Describe your symptoms/pain: Recent onset date *
13. What is your level of pain and is this interfering with your daily life. 10 being highest. *
14. How long have you had these symptoms? . *
15. List any medications *
16. List ANY surgeries (including elective) and the year/date *
17. Indicate areas of pain below *
Check all that apply. *

Head/jaw Neck Pecs/Chest Shoulders Wrist Elbow Upper back Mid back Low back Hip Legs Knee Lower leg/calves Other
18. Check below if you have any of the following medical conditions.
Check all that apply. *

Heart Disorder High blood pressure Hernia or Hernia repair Pacemaker Cancer Kidney Issues Edema/Swelling Diabetes Pregnant Lymphedema Broken bones Angina Osteoporosis Herniated/Bulging disc Phlebitis Infectious disease Other:
19. Explain if you answered yes to the above question. *
20. What are your goals? (besides pain relief) Example: Get back to playing golf.. etc *
21. Who may we thank for referring you to us? *
With my help as your Health Care Practioner, you are going to greatly improve your ability to accomplish your health goals faster, safer and with maximum benefits. Plus, the tools and strategies you will learn during our time working together can be used for a lifetime.

Just as would be the case if you were working with a personal trainer at a gym or a nutritionist in a medical office, the following expectations must be met with regards to our sessions:

1. Sessions that are not rescheduled or cancelled 24 hours in advance will result in forfeiture of the session and/or a loss of the financial investment at the rate of one session.

2. Cliens arriving late to session will receive the remaining scheduled session time, unless other arrangments have been previously made.
22. I have read the above Agreement and agree to its terms. *

Yes
WAIVER OF LIABILITY
I understand that massage/manual therapy/posture exercise therapy should not be construed as medical diagnosis, medical exam or medical treatment - I have stated all medical conditions and will inform you of any changes in my health.

I agree that if I engage in any therapies performed or recommended by Body & Soul Wellness Center (therapist) or any recommended activity, I do so at my own risk. This waiver and release of liability includes, without limitation, all injuries which may occur as result of (A) your participation in any activity or participation in any ope of massage modality and (b) instruction, training supervision, recommendations by therapist at Body & Soul Wellness Center.

I acknowledge that I have carefully read this "waiver and rélease" and fully understand that it is release of liabity. I expressly agree to release and dischange Body & Soul Wellness Center from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring legal action against Body & Soul Wellness Center for personal injury or property damage. By signing this you acknowledg and understand its concent and that this release cannot be modified orally.
I have read the above Waiver of Liability and agree to its terms. *
MUTUAL GOAL AGREEMENT
As your Health Care Practioner, my goal is to help you reach your goals. Once I help you reach those goals, I ask that you help me reach my goal, which is to help other clients like you to succeed.

Once you've reached your goals would you connect me with people you know who could use my help? Does this sound like fair deal?

24. I have read the above Mutual Goal Agreement and think this is a fair deal:
Mark only one. *

Yes No
25. Is there anything else you'd like to share? If so, please do so here
I agree that all information provided on this form is accurate to the best of my knowlegde. *

agree
27. Type your full name here as your digital signature

Clear
28. Date *

Month Day Year
Date
Example: January
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WAIVER OF LIABILITY

MUTUAL GOAL AGREEMENT