Client Information

Your Name* This field is required.

First Name

Last Name

Is this your first appointment or workshop with me?* This field is required.

YesNo

Has anything changed in your health or life situation since we last met?* This field is required.Any recent accidents or injuries? Any changes to stress level? New medications? New health conditions? Any improvements?

What is your age?* This field is required.

Your contact details:* This field is required.Please enter your preferred email and telephone number

Best email address to reach you:

Best phone number to reach you?

Emergency Contact:Who should I contact in case of emergency?

Name

Phone Number

What is their relationship to you? (Spouse, family member, friend etc)

How would you rate your current state of health?

Are you diabetic?

YESNO

Do you have high blood pressure?

YESNO

Are you pregnant?

YESNO

Do you have frequent headaches or migraines?

YESNO

Are you under psychological treatment?

YESNO

Do you currently smoke?

YESNO

Do you have a neurological condition? Have you ever suffered a brain injury or head trauma?If yes, please explain. List dates if applicable.

Do you have a chronic illness?If yes, please explain.

Are you taking any prescription drugs or medications? Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.

Have you ever had a car accident or an injury of any kind?Please list any car accidents, falls, broken bones, sprains etc, and dates they happened. (For example: sprained ankle 1999; head on collision 2000; concussion due 2002; broken wrist 2004, carpal tunnel 2013; plantar fasciitis 2015)

Have you ever had surgery?If yes, please indicate what type of surgery and when. (Even if it happened a long time ago)

Please rate the following:(Drag the slider left or right)

Do you currently have an injury? Have you recently had surgery? If so, please describe below, including dates if you can.

Current Areas of Concern:What brings you to the this workshop? What kind of results are you seeking?

What other treatments/therapies are you undergoing?

Physiotherapy

Massage / RMT

Chiropractor

Craniosacral

Acupuncture

Naturopath

Osteopath

Exercise / Training

Pilates

Other

What is your goal for this workshop?What is your ideal outcome? What results do you hope for?

How did you hear about me?If someone referred you, please let me know their name so I can thank them!

Liability Waiver I understand that any exercise and/or fitness activities involve a risk of injury, and that I am voluntarily participating in these activities with understanding and appreciation of the risks involved. I hereby agree to hold harmless Jennifer Bodmer, and Jennifer Bodmer Enterprises, and expressly assume and accept any and all risks of injury, regardless of severity.

General Photography ReleaseI hereby authorize Jennifer Bodmer or Jennifer Bodmer Enterprises to publish photographs taken of me at any MELT class or workshop, and my likeness, for use by Jennifer Bodmer or Jennifer Bodmer Enterprises for print and online marketing materials. I hereby release and hold harmless Jennifer Bodmer or Jennifer Bodmer Enterprises from any reasonable expectation of privacy or confidentiality associated with the images specified above. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type for these photographs.

Client Information