Name
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First Name
Last Name
Email
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Phone
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(###)
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Preferred contact method
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Call
Text
Email
Address
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Date of Birth
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MM
DD
YYYY
Occupation
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On a scale of 1-10, how stressed are you currently? 1= no stress and 10=the most stressed.
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How well do you balance work, recreation, and self care?
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Primary concerns/goals which brought you to Bodily Kneads:
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Are you currently under the care of a medical Doctor or licensed health care professional for any of the above concerns? If yes, physicians name and contact #:
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Are you currently taking pain medications or blood thinners? If so, please list:
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Do you have any allergies ? Food, environmental, or medicinal? If yes, please list:
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Do you have a pacemaker?
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Yes
No
Past trauma (physical or emotional) or accidents?
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Any past surgeries? Please include dental work.
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Please select any of the conditions you have had, past or present:
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Any other conditions not listed above?
How did you find out about Bodily Kneads?
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Myofascial Release/Massage (MFR) is contraindicated for specific conditions. In those cases a referral from a primary care physician may be required. Failure to disclose medical conditions, for which MFR is contraindicated, could result in injury or exacerbation of symptoms for which my therapist will NOT be held legally responsible. Bodywork is not a substitute for a medical exam, diagnosis or treatment. It is my responsibility to consult the appropriate qualified medical specialist for mental or physical ailments that are beyond the scope of practice for my MFR Practitioner. I understand that the therapist does not diagnose illness, disease or medical disorders, nor perform spinal manipulation. It is my responsibility to update my therapist with any changes to my medical history. Any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for the full payment of the scheduled appointment. I will be charged full price for appointments cancelled without a 24- hour notice if an alternate client is not able to fill the allotted time. By signing below, I agree to the above statements.
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