Stretch Therapy Health Intake Form

Conversational Form (#5) (#7)

(required for all stretch clients)

Your Name

Phone

Emergency Contact & Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Medical History

Please share your past medical history with us.

Surgeries within the last 10 years?

Any joint replacements or internal fixation surgeries?

Other Medical History You Wish To Share (please specify):

Other Areas of Discomfort You Wish To Share (please specify):

Describe the issue(s), including severity and duration:

Are there any pain triggers or activities of daily living that are compromised as a result of your current condition?

Do you currently stretch regularly?

How often do you exercise or engage in physical activity?

Movements that cause discomfort or pain?

If yes, please explain:

Personal & Lifestyle Info - Occupation:

Personal & Lifestyle Info - Hobbies:

Personal & Lifestyle Info - Special Considerations:

Personal & Lifestyle Info - Goals for Stretch Therapy:

I have read and agree to the Terms for - Massage Policies and Guidelines

Consent & Release - I understand that stretch therapy involves assisted movement and body positioning. I have disclosed all medical conditions and physical limitations, and I understand that stretch therapy is not a substitute for medical care. I release my practitioner from any liability for issues that may arise from undisclosed conditions or my own participation.

Stretch Therapy Health Intake Form

Stretch Therapy Health Intake Form(required for all stretch clients)

Stretch Therapy Health Intake Form

Medical History

Stretch Therapy Health Intake Form
(required for all stretch clients)