Bodywork and Somatic Session - PLP Health Screen
Please fill out this form carefully to help us understand your health background and ensure a safe and effective session.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Medical History and Current Conditions
*
Have you had any recent surgeries?
Do you have any ongoing medical conditions?
Do you have any heart conditions?
Do you have any neurological conditions?
Do you have any infectious diseases?
Are you under the care of a healthcare professional?
*Women - are you pregnant?
Please specify any injuries, pain areas, Psychological Trauma’s or other health information. Please include any other information that may be relevant.
What’s your Intention to experience from session/s?
Please note any medications you are currently taking. List any allergies (e.g., medications, foods, environmental). Relevant allergies could be environment as well as massage oils etc.
Are you familiar with boundaries and consent? Are you able and willing to respect boundaries of the practitioner? Do you have any personal boundaries you’d like to express?
If you could create your ultimate session, what does it look like? How do you feel when the sessions complete?
Additional Information
Do you have any other health-related concerns?
Is there anything else you would like us to know before the session?
Consent and Acknowledgment
*
I understand that the session involves physical touch and movement. I acknowledge that I have disclosed all relevant health information.
I agree to inform the practitioner of any discomfort during the session.
I agree to respect both my own boundaries and the practitioners.
Submit Health Screening
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