Stretch Therapy Health Intake Form Please fill out the Stretch Therapy Health Intake Form below! REQUIRED FOR ALL NEW STRETCH PATIENTS. Please answer every question. If you don’t have an answer, write N/A. Stretch Therapy Health Intake Form(required for all stretch clients) 1 Client Information 2 Medical History 3 Stretching History & Activity Level 4 Signature 0% Full Name * Address * Email * Phone Number * Emergency Contact & Phone number * Previous Next Medical History Please share your past medical history with us. Surgeries within the last 10 years? Any joint replacements or internal fixation surgeries? Medical History (Please Select All Those Which Apply) Joint replacements (hip, knee, shoulder, etc.) Herniated or bulging discs Sciatica or nerve pain Arthritis or joint pain Osteoporosis or osteopenia Recent surgery or injury (within the past 6 months) High blood pressure Heart conditions Diabetes Fibromyalgia Chronic pain Strains or Sprains Other (please specify): Areas of Discomfort Neck Shoulders Upper Back Lower Back Hips Knees Ankles/Feet Wrists/Hands Other (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? Previous Next Do you currently stretch regularly? Yes No How often do you exercise or engage in physical activity? Rarely 1-2 times/week 3-5 times/week Daily Movements that cause discomfort or pain? Yes No If yes, please explain: Goals for Today's Session Pain relief Improve flexibility Increase range of motion Stress relief Athletic performance/recovery Personal & Lifestyle Info - Occupation: Personal & Lifestyle Info - Hobbies: Personal & Lifestyle Info - Special Considerations: Personal & Lifestyle Info - Goals for Stretch Therapy: Previous Next I Accept These Terms - 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. Signature Sign digitally using your mouse, touchscreen, or a digital pad. Clear Undo Redo Submit Previous Next
