First Time Client Intake Form
Please take a moment to answer the general health questions and review and agree to our policy's and procedures. Filling out this form PRIOR to your treatment will allow for more time with you during your initial session and helps me customize the session for your specific needs. Thank you! Prior to treatment please remember to remove jewelry - especially necklaces; pull long hair back and wear modest, loose comfy clothes for freedom of movement.
Name
First Name
Last Name
Date Of Birth (00/00/0000)
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact: Include Name, Phone Number, and Releationship
Are you currently under the care of a Physician
Yes
No
If Yes, Please Explain and Clarify if you have any medical conditions/ Diagnosis major accidents, injuries, or surgeries StretchSpa, LLC should know about.
Note: I am unable to diagnose and will refer out if there are health signs that are contraindicated for my services.
Do you have any special medical needs or considerations? (For Example, Use of wheel chair, walker, have shortening / hardening of muscles, known as a contracture, ETC).
Yes
No
If Yes, Please Explain
What are your goals and expectations from your StretchSpa, LLC Session?
Are you or do you think you are pregnant?
Yes
No
Do you have any Head/Neck concerns such as headaches, migraines, ringing in ears, vertigo/dizziness, vision or hearing loss, etc?
Yes
No
If yes, please explain:
Are you able to independently ambulate up and down one flight of stairs with use of a single handrail?
Yes
No
Do you Suffer from any neurological disorders, such as seizures, epilepsy, MS, Parkinsons, Neuropathy/numbness, sciatica, or any sensory loss?
Yes
No
If yes, Please Explain
Have you been diagnosed with any musculoskeletal disorders such as arthritis, osteoporosis, bursitis, tensonitis, jaw pain, Pins/plates/Wires, or any artificial joints
Yes
No
If yes, please explain.
Do you suffer any respiratory or cardiovascular issues such as asthma, cough, shortness of breath, sinusitis, emphysema, smoker or history of smoking, high or low blood pressure, stroke, heart disease, pacemaker, hemohilia, phlebitis/varicose veins, etc.?
Yes
No
If Yes, please explain:
Do you have any skin disorders or other health infections such as Lyme Disease, HIV/Aids, Herpes, Hepatitis, etc?
Yes
No
If Yes, Please explain:
Please advise if you have any other conditions such as Cancer, Depression, Chronic Fatigue, Fibromyalgia, etc.
Are you Diabetic
Yes, it is controlled
Yes, it is not controlled
No
If yes, please explain any loss of sensation or mobility:
Please Rate your daily activity level:
Sedentary, seated work for 4-8 hrs a day walking as needed
Average, Good mix of seated, standing, walking activities
Above Average, general seated standing, walking and exercise 1-3 x a week
High, rarely seated, and exercise 5 or more days a week
Are you in, or do you have any significant discomfort? Please describe where you discomfort, what type of discomfort you are experiencing (dull, sharp, radiating, numbness, tingling, etc) and how severe is the discomfort using a scale of 1-10 with 10 being the most severe/requiring an emergency room visit):
Do you have any Allergies to lotions, oils, creams, waxes, adhesives, or dog fur:
Yes
No
If Yes, please explain:
I understand that services provided by StretchSpa, LLC practioners are provided for stress reduction, relaxation, relief from muscular tension, whole body wellness, and improvement of circulation, improvement of range of motion and energy flow
Yes
If I experience pain/discomfort during the session, I will immediately inform my practitioner so that adjustments can be made to accommodate for my level of comfort. I will not hold my practitioner liable should I choose not to say anything if I have discomfort.
Yes
I have notified my StretchSpa, LLC practitioner of all known medical conditions. I agree to inform my practitioner of any changes in my health and medical condition at current or future appointments. I understand there shall be no liability on the practitioner's part should I forget to do so.
Yes
I understand that services at StretchSpa, LLC are non-sexual in nature and any exposures of skin will be met with proper draping to ensure client privacy and to client comfort level and this will be discussed prior to the session. Services are strictly professional
Yes
I understand there is a 24 hour cancellation policy and if I am unable to cancel prior to 24 hours I may be responsible for the costs associated with the session, and may be rquireed to pay prior to any additional sessions. Any No Show appointment is responsible for the full amount and if paid in advance will NOT be refunded.
Yes
I understand that if I arrive late to my appointment, only the allotted time remaining will be utilized and I am responsible for the full payment.
Yes
I understand that the services offered today are not a substitute for medical care, nor a substitute for any medical examination or diagnosis and services are not billable to my insurance.
Yes
I understand that my practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness.
Yes
I am over the age of 18. If I am under the age of 18, I must be accompanied by an adult for in person sessions, and an adult over 21 must be present for virtual/online appointments. NO EXCEPTIONS.
Yes
No
If no, please provide name, relationship, and phone number of adult or guardian accompanying client under age of 18.
(required)
Please identify and thoughts, questions, concerns, or include any preference of Pandora or artist you prefer to listen to during your appointment.
By Signing this release I hereby waive and release my practitioner, Nancy Griffith, StretchSpa, LLC, and all staff, affiliates, or contractors, from any and all liability, past, present, and future, whether in person, or virtual/online, relating to StretchSpa, LLC services. I affirm that I have notified my practitioner of all known medical conditions and injuries, and will notify of any changes to my health or medical conditions. I am also choosing to arrive for treatment and will not attend if I feel that my health is at risk, or if I have signs of illness or sickness, including fever, or if I am a risk to others. Cancellation fees are waived for appointments due to illness with rescheduled appointments. We are committed to providing a welcoming, safe, comfortable atmosphere for everyone regardless of orientation. All services are professional and non-sexual.
Client Signature (required)
Submit
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