Client Information for Bodycentric Healing ArtsThis Client Information Form can be printed and filled out prior your first appointment or filled out in our office (please arrive 10 minutes early to fill out). This will be used as a guide when we discuss your treatment plan. If you have any questions, please don't hesitate to call us: 610.200.8008 We look forward to working with you. The Bodycentric StaffPlease enable JavaScript in your browser to complete this form.Name *FirstLastStreet AddressCity - State - Zip CodePhone number where you can be reached during business hours and messages can be left. *E-mail address *Your OccupationDate of Birth - Age - Sex - Gender In Case of Emergency - Name and Phone numberPrimary reason for this appointmentPrimary Care PhysicianPlease list any other medical or healthcare practitioners seen recentlyChiropractor, Physical Therapist, Acupuncturist, Nutritionist, Bodyworker, OtherPlease list any specialists you have seen recentlyHow did you hear about us?Have you ever experienced a professional massage or bodywork session?YESNOIf yes, how recently?Reasons for this appointment - Select all that may applyGeneral WellnessPain Relief & DiscomfortImprove Posture/formAchieve BalanceNutritional CounselingMBS IntegrationRelaxation/STress ReductionImprove Movement & FunctionDetoxify & ClearingLifestyle CoachingSpiritual/Emotional SupportWhat goals are you looking to attain from your session?If the above condition is related to an accident or injury, please describe the incident briefly and when it occurred.Does the above condition interfere with your work?YESNODoes the above condition interfere with your sleep?YESNODoes the above condition interfere with recreation?YESNODo you have any other medical condition(s) that the therapist should be aware of prior to administering any form of massage/bodywork?YESNOIf yes, please specifyAre you pregnant?YESNODo you exercise? YESNOWhat type of exercise & how often?Do you wear contact lenses? YESNODo you have dentures? YESNODo you wear a hearing aid? YESNODo you have a defibrillator or pacemaker?YESNODo you have any implants?YESNOIf you checked yes, please list them below.Please list all medications that you are currently takingMUSCULO-SKELETALArthritisTMJ dysfunctionHerniated DiscBursitisOsteoporosisSciaticaTendonitisOther spine problem(s)OtherPlease check any of the conditions that you are currently experiencing or have recently experienced.If you checked Other, please explain CIRCULATORYVericose VeinsHigh Blood PressurePhlebitisAneurysmHeart ConditionAtrial FibrilationBlood ClotsLow Blood PressureArteriosclerosisEasy BruisingStrokeOtherPlease check any of the conditions that you are currently experiencing or have recently experienced.If you checked Other, please explainDIGESTIVEConstipationSpastic ColonStomach UlcerIrritable BowelIndigestionUlcerated ColonAbdominal PainColitisOtherPlease check any of the conditions that you are currently experiencing or have recently experienced.If you checked Other, please explainMISCELLANEOUSCold hands/feetHeadachesFatigueCold or FluSevere DepressionAsthmaSkin ConditionsRecent SurgeryInsomniaRecent Internal BleedingNumb hands/feetMigraine HeadachesFaintingShortness of breathSensitivity to lotionsCancerDizzinessNerve painHepatitisDiabetesIf you checked Other, please explainFEMALESPMSMenstrual crampsCurrent pregnancyOtherPlease check any of the conditions that you are currently experiencing or have recently experienced.If you checked Other, please explainYour Name & today's date *Parent or Guardian's Name & today's datePlease check this box *I understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician or other qualified medical specialist for any medical or physical ailment of which I am aware. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.Checking the box is required.APPOINTMENT TIMEWe endeavor to provide the highest quality service possible. Please arrive at your scheduled time. This will allow for maximum relaxation and treatment. Arriving late will result in a shorter appointment. This time is designated for you and payment for the scheduled time is required at the time of service. Cash and checks are accepted, as well as Visa, Mastercard, and Discover.LATE CANCELLATION, MISSED APPOINTMENT/NO SHOW 48-HOUR NOTICE IS REQUIRED. Payment in full will be expected for any cancellation with less than 24 hours notice.HEALTH UPDATE: Massage and Bodywork is provided for your healthcare needs. Please keep us informed regularly of changes in your medical condition and profile. Clear and honest communication is essential as well as confidential.ETHICS: We provide services within the scope of A.B.M.P. definition of massage, bodywork, somatic therapies, and the boundaries of our training. We will not employ those techniques for which we have not had adequate training and shall represent our education, training, qualifications, and abilities honestly. Behavior of a sexual nature will not be tolerated. Any implication, remarks, or advances will result in termination of the session. Payment for the scheduled appointment will be expected. Consent to Treatment of a MinorBy checking this box, I hereby authorize Bodycentric Healing Arts to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.Please check this box *I understand and agree to the policies and procedures listed above.Email *NameThank you
