• Musculoskeletal Recovery & Treatment Intake

    All information is held confident. At no given point is information disclosed or shared without client’s written consent. 
    Musculoskeletal Recovery & Treatment Intake
  • Format: (000) 000-0000.

  • Health Information

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  • 4. Frequency (check all that apply)*
  • 5. At what time of day is the pain at its worse (check all that apply)?*
  • 8. Difficulty with any of these activities*
  • 9. List all related treatments received for this injury/symptom (check all that apply)*
  • 13. Current Medications*
  • 14. Allergies*
  • 15. Sensitivities*
  • Head Symptoms (check all that apply)
  • Neck Conditions (check all that apply)
  • Shoulder Conditions (check all that apply)
  • Arms & Hands Symptoms (check all that apply)
  • Mid-Back Symptoms (check all that apply)
  • Low Back Symptoms (check all that apply)
  • Hip Symptoms (check all that apply)
  • Legs and Feet Symptoms (check all that apply)

  • Physical Patterns

  • Occupation requires (check all that apply)*
  • Primary sleeping position*

  • Client Agreement & Informed Consent
    By signing below, I acknowledge and agree to the following:

    Remedy specializes in recovery-focused care designed to address musculoskeletal tension, mobility restriction, postural stress, and chronic compensation patterns.

    I understand that services provided at Remedy Neuromuscular Therapy are intended to support musculoskeletal recovery, mobility, stress reduction, and general wellness through therapeutic and recovery-focused modalities which may include neuromuscular therapy, manual therapy, assisted stretching, compression therapy, hot/cold application therapies, photobiomodulation (LumaHeal red light therapy), percussion/shockwave-style modalities, and related techniques when appropriate.

    I understand that these services are not a substitute for medical diagnosis or medical treatment provided by a physician or other licensed healthcare provider.

    I affirm that I have disclosed all known medical conditions, injuries, surgeries, medications, sensitivities, implants, and other relevant health information that may affect my treatment or safety. I understand that failure to disclose relevant medical information may increase risk during treatment.

    I understand that I am responsible for informing my practitioner immediately if I experience pain, dizziness, numbness, discomfort, skin irritation, light sensitivity, shortness of breath, or any unusual physical response during or after treatment.

    I understand that treatment outcomes vary between individuals and that no specific results or guarantees have been promised.

    I understand that certain modalities may not be appropriate for all individuals or conditions and that Remedy reserves the right to modify, postpone, or decline treatment when clinically appropriate or when client safety may be compromised.

    I acknowledge that therapeutic touch and manual techniques may involve temporary soreness, tenderness, redness, bruising, fatigue, emotional release, or symptom aggravation as part of the body’s response to treatment and recovery processes.

    I understand that maintaining hydration, movement, home care recommendations, posture awareness, stretching, exercise habits, stress management, and general lifestyle factors may influence treatment outcomes.

    I consent to receive therapeutic and recovery-oriented services provided by Remedy Neuromuscular Therapy.

    I authorize Remedy Neuromuscular Therapy to communicate with me regarding scheduling, appointment reminders, wellness updates, recovery recommendations, promotions, and related business communications unless I opt out.

    Professional Conduct & Session Safety
    Remedy Neuromuscular Therapy maintains a professional therapeutic environment at all times.

    Any inappropriate, sexually suggestive, aggressive, discriminatory, or otherwise disrespectful behavior toward staff or practitioners — including comments, gestures, advances, requests, or physical actions — will result in the immediate termination of the session and refusal of future services.

    Clients are expected to maintain professional boundaries and communication throughout all interactions and treatment sessions.

    Remedy reserves the right to end or decline treatment at any time if client behavior compromises practitioner safety, professionalism, or the therapeutic environment.

    Treatment Areas & Draping Acknowledgment
    I understand that certain treatments may involve work near or around sensitive anatomical regions, including but not limited to the chest/pectorals, gluteal region, hips, inner thigh, abdomen, jaw, or upper neck when clinically relevant to the treatment goals discussed.

    I understand that only the specific area being treated may be temporarily exposed for therapeutic purposes and that professional draping procedures will be maintained throughout the session to support privacy, safety, and client comfort.

    I understand that I may communicate discomfort, request adjustments, decline treatment to specific areas, or withdraw consent for treatment at any time during the session.

    By my electronic signature below, I agree to the policies and agreement above.

  • Acknowledgement*
  • Should be Empty: