New Client Intake Form
Bryony Pullin, LMT, CYT - Massage, Reiki, Ortho-Bionomy, Yoga, Meditation
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact and Phone Number
Occupation
Types and frequency of physical activity
Have you received any kind of bodywork or energy work before? (Massage, chiropractic, Reiki, etc).
Yes
No
Please indicate if you have had, or currently experience, any of the following:
Migraines
Vertigo
Eye pain/vision problems
Whiplash
TMJD
Shoulder pain or injury
Elbow pain or injury
Carpal Tunnel Syndrome or other wrist pain
Arthritis
Spine problems, such as herniated disc
Scoliosis
Sciatica
Sacro-iliac Joint Dysfunction
Restless Leg Syndrome
Hip pain or injury
Knee pain or injury
Ankle pain or injury
Foot pain or injury
Bunions
Fallen arches
Strain/Sprain
Muscle Cramps
Heart Disease
High/Low Blood Pressure
Asthma
Hypoglycemia
Diabetes
Insomnia
Glandular dysfunction
Allergies
Fibromyalgia
Colitis/IBS
Constipation
Cancer
HIV/AIDS
Chronic Stress
Acute Stress
Depression
Anxiety
Sleeping difficulty
Other
Please describe any recent or past injuries, and surgeries.
Please list any medications, including herbal/vitamin supplements, and what you are using them to treat:
Please describe any physical concerns you are currently experiencing.
Please rate your current physical comfort on a scale of 1-10, 1=very painful, 10=very comfortable
As our mental/emotional stressors often affect our physical comfort, please rate your current stress level on a scale of 1-10, 1=very stressed, 10=very comfortable
When you think about the issues that cause you stress, where do you feel that in your body?
What would you most like to get out of our work together, i.e. your intention for the work?
In signing below, you acknowledge that the services offered by Bryony Pullin, LMT, CYT are not a substitute for medical care, and that any information provided by the therapist is for educational purposes only and is not diagnostically prescriptive in nature. With your signature, you agree to actively participate in your own well-being and healing process.
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