Intake Form

Welcome! I look forward to working with you.

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First and last name

Pronouns

Date of Birth

Emergency Contact (name, relationship, phone number)

How did you hear about us?

What brings you here? Do you have specific goals or concerns you would like to address with shiatsu?

Have you previously experienced any form of bodywork/massage? Please describe:

Please list any medications, herbs, vitamins and supplements you take:

It is important that your bodywork practitioner knows if you are currently experiencing or have previously experienced any of the following medical conditions. Please specify all that apply and add any comments in the box below (or write “no” if none apply):

blood clots……
cancer……
diabetes……
epilepsy/seizures……
heart condition…..
hypertension/high blood pressure……
osteoporosis…..
varicose veins

Do you have reason to believe you may be pregnant?

Bodywork can address a variety of health issues. Are there any other complaints, irregularities or medical conditions of which you would like your practitioner to be aware (allergies, respiratory conditions, digestive issues, sleep difficulties, low energy, anxiety, depression, etc.)?

Have you had any surgeries, broken bones, orother serious injuries within the last 3 years? Please describe if so:

Would you like to receive emails from Kate, once a month or less, with promotions and news?

Is there anything else you’d like to share?

I understand that bodywork is for the well being of my body, mind and spirit and is in no way a form of medical treatment. I have not been promised anything to submit to these procedures, or to sign this release form. No guarantees or warranties have been made to me as to the success, value, or benefit of such procedures. (signature)

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