New Client Intake Form

Name*

First NameLast Name

Email*

example@example.com

Age / Weight / Height*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Name*

Emergency Contact Phone Number*

What brings you to Body Moxie?(Examples: injury recovery, improved mobility, pain reduction, strength training, athletic performance, postural work, general wellness)*

What are your main goals for training or treatment in general?*

Current Concern: Please describe the main issue you would like help with today. Include when it started, what may have triggered it (injury, activity, gradual onset, etc.), where you feel it, and whether the discomfort travels to other areas. What makes it better?*

When do you notice the discomfort the most, and how would you describe the sensation? Examples: sitting, walking, lifting, sleeping, exercise; sharp, dull, aching, burning, tightness, stiffness, instability.

Pain or discomfort level (0–10)0 = no pain10 = worst pain imaginableWhat tends to make it worse? What helps relieve it?

Medical Evaluation: Have you seen a medical professional for this issue? If yes, what type of provider? MD / Physician, Physical Therapist, Chiropractor, Other*

Have you had any imaging or tests for this issue?*

Have you ever sprained an ankle?*

Have you ever been in a car accident? Please describe and list dates. *

Do you currently wear orthotics or shoe inserts?*

Describe any minor or major falls (i.e., loss of balance, bathtub, ice, etc):*

If you get headaches, describe the location:

Are you a smoker of tobacco?*

List daily exercise routine:*

In general, where do you hold your tension in your body?*

Do you grind your teeth? Or chew gum?*

Do you have sleep apnea?*

Are you pregnant?*

Do you have ANY SCARS from INJURIES or SURGERIES? List all, even the small ones as they are important for assessment. *

Any types of surgical procedure, minor or major? Dates?*

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*

Do you feel pain in your chest when you perform physical activity?*

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Is your doctor currently prescribing medication for your blood pressure or for a heart condition?*

Do you know of any other reason why you should not engage in physical activity?*

Have you ever had a concussion or minor head injuries?*

Anything else in your medical history that's important to know?*

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,

AND INDEMNIFICATION AGREEMENT

1. Participant Agreement
This Release and Waiver of Liability, Assumption of Risk, and Indemnification Agreement (“Agreement”) is entered into by the undersigned participant (“Participant”) in connection with participation in any services provided by Body Moxie, LLC and Christine Wue (“Provider”).

Services may include, but are not limited to:

movement instruction
exercise or physical training
corrective exercise
movement assessment
manual muscle testing
hands-on demonstration or manual techniques
consultation or coaching
mentorship or educational sessions for practitioners
observation or participation in demonstrations
virtual or remote sessions conducted through video platforms.
These services are collectively referred to as the “Training.”

Training may occur in private sessions, group settings, mentorship environments, educational demonstrations, or through remote communication platforms.

By signing this Agreement, Participant acknowledges and agrees to the following:

2. ASSUMPTION OF RISK
Participant understands that participation in Training involves physical activity and hands-on interaction that carries inherent risks.

Such risks may include, but are not limited to:

muscle soreness or fatigue
strains, sprains, or tears
dizziness or fainting
aggravation of existing injuries or medical conditions
slips, falls, or equipment-related injuries
serious injury, disability, or death.

Participant understands that risks may arise from:

physical exercise or movement activities
manual muscle testing or physical assessment
hands-on demonstrations
use of equipment or studio facilities
actions of the Provider, Participant, or other individuals present.

Participant voluntarily and knowingly assumes all risks, whether known or unknown, associated with participation in the Training.

3. CONSENT TO PHYSICAL CONTACT
Participant acknowledges that Training may involve appropriate physical contact, including manual muscle testing, movement assessment, or demonstration of techniques.

Participant voluntarily consents to such contact as reasonably necessary for instructional or assessment purposes.

4. RELEASE AND WAIVER OF LIABILITY
In consideration for being permitted to participate in Training, Participant hereby releases, waives, and discharges the Provider from any and all claims, demands, causes of action, damages, or liabilities arising out of or related to participation in Training.

This release includes claims for:

personal injury
illness
property damage
economic loss
disability or death.

This release expressly includes claims arising from the negligence of the Provider, to the fullest extent permitted by law.

Participant understands that by signing this Agreement they are waiving certain legal rights, including the right to bring a lawsuit against the Provider for injuries or damages resulting from participation in Training.

5. MENTORSHIP AND EDUCATIONAL SESSIONS
Participant understands that Training may occur in educational or mentorship settings, including instruction related to movement assessment methods such as NeuroKinetic Therapy and manual muscle testing.

In such settings:

other practitioners, trainees, or mentees may be present
Participant may be observed by others for educational purposes
Participant may be used as a demonstration subject for teaching techniques.
Participant acknowledges and consents to such participation.

If Participant is introduced by another practitioner, trainee, or mentee, Participant understands that:

the practitioner introducing them remains responsible for their professional relationship with the Participant
the Provider is acting primarily in an educational or instructional capacity
the Provider is not assuming responsibility for diagnosis, treatment, or ongoing care of the Participant.

This Agreement applies fully to participation in such mentorship or educational settings.

6. THIRD-PARTY PARTICIPANTS
Participant understands that individuals attending Training may include:

clients of other practitioners
students or trainees
observers in educational settings.

The Provider is not responsible for the professional conduct, services, or advice of other practitioners or participants.

7. REMOTE OR VIRTUAL SESSIONS
Participant acknowledges that Training may occur remotely through video conferencing or other digital platforms.

Participant understands that remote sessions may limit the Provider’s ability to fully evaluate:

physical condition
movement patterns
equipment safety
environmental hazards.
Participant assumes all risks associated with participating in remote Training.

8. MEDICAL ACKNOWLEDGMENT
Participant understands that the Provider is not a physician or licensed medical provider.

Training is educational and movement-based and is not intended to diagnose, treat, or cure any medical condition.

Participant represents that they:

are physically capable of participating in Training
have consulted with a physician or healthcare professional if necessary.

Participant agrees to immediately stop participation and inform the Provider if they experience:

pain
dizziness
discomfort
or other concerning symptoms.

9. NO GUARANTEE OF RESULTS
Participant understands that the Provider makes no guarantees regarding outcomes or results from participation in Training.

Individual results may vary.

10. EMERGENCY MEDICAL CONSENT
Participant authorizes the Provider to obtain emergency medical assistance if necessary.

Participant agrees that they are responsible for any medical costs incurred as a result of such treatment.

11. INDEMNIFICATION
Participant agrees to indemnify, defend, and hold harmless the Provider from any claims, damages, liabilities, losses, or expenses (including reasonable attorney’s fees) arising from participation in Training.

12. WAIVER OF UNKNOWN CLAIMS
Participant acknowledges that they are aware of and expressly waive the protections of California Civil Code §1542, which states:

“A general release does not extend to claims which the creditor does not know or suspect to exist in their favor at the time of executing the release.”
Participant knowingly waives these protections.

13. GOVERNING LAW AND VENUE
This Agreement shall be governed by and interpreted in accordance with the laws of the State of California, regardless of the Participant’s location.

Any dispute arising from this Agreement or participation in Training shall be brought exclusively in the courts located in San Mateo County, California, and Participant consents to the jurisdiction of those courts.

14. SEVERABILITY
If any provision of this Agreement is found to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

15. CONFIRMATION OF UNDERSTANDING
By signing this Agreement, Participant acknowledges that they:

have read this Agreement carefully
fully understand its terms
understand that they are waiving certain legal rights
voluntarily agree to be bound by this Agreement.
Participant acknowledges they have had the opportunity to ask questions or seek legal counsel prior to signing.

16. ELECTRONIC SIGNATURE
Participant agrees that an electronic signature submitted through an online platform shall be legally binding and have the same force and effect as a handwritten signature.

Body Moxie New Client Intake Form