ST8NEWALKERS' PRINTABLE CLIENT INFORMATION FORM   
Copyright Hillbunny Productions, 2000-2016 All Rights Reserved  www.ST8NEWALKER.com

605-722-0004

Please PRINT, FILL OUT, SIGN and BRING this form with you for your first session

My first appointment is scheduled for

Date of:__________________________Day:__________________Time:_____________
If you cannot make this scheduled appointment date as agreed, Please call at least 12 hours in advance of appointment to cancel.

 Name______________________________________________________________________________________

 Address________________________________________City__________________State______Zip_________

 Home Phone_____________________Email:________________________Cell phone:___________________
I
f you have a specific medical condition or symptoms, bodywork may be contraindicated or a referral from your primary care provider may be required prior to service being provided.  Please be advised that the following necessary information will be kept in strict confidence, and on file only for insurance purposes /or to inform practitioner so that appropriate therapies may be administered and/or contraindicated.  Please list brief explanation of your physical complaints " health concerns:

(Please Check Yes or No to indicated your specific issues, health related challenges, use back of form to explain specifics)

YES

NO

 

Please explain current symptoms, treatments, medications you are taking, other

 

 

Allergies (please list)

 

 

 

Arthritis

 

 

 

Blood Pressure High/Low

 

 

 

Diabetes (list all related complications)

 

 

 

Emotional trauma, childhood issues

 

 

 

Epilepsy or Seizures

 

 

 

Heart - Cardiac/Circulatory Problems

 

 

 

Kidney, Liver, Spleen issues

 

 

 

Lower Back Issues (please list specific)

 

 

 

Pregnant (currently?)

 

 

 

Skin Problems/Rashes/Hives

 

 

 

Sleep issues, Fatigue, Weakness, Fibromyalsia

 

 

 

Sore Spots or sensitivities?

 

 

 

Stroke

 

 

 

Surgeries (please list specific)

 

I understand that I am responsible for my own health and I have chosen to receive this therapy for my own education and health reasons, and that all services I receive are provided for the basic purpose of relaxation and relief of stress factors.  If I experience any pain or discomfort during a session, I will immediately inform the practitioner so that the discomfort may be addressed.  I further understand that bodywork should not be construed as substitute for medical examination, diagnosis, or treatment, and that practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such. I affirm that I have stated all my known health conditions, and answered all questions honestly.  I agree to keep practitioner updated as to any changes in my health profile and I understand that there shall be no liability to practitioner should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also agree to take personal responsibility to consume adequate fluids and nutritious foods as well as allow time for rest following each session to best encourage and compliment my body's healing response to massage therapies.

Client Signature (or signature of legal parent or guardian if minor):  

__________________________________________________________________________________________________Date:_______________