ELYSIAN FIELDS

Neuromuscular Therapy

Client Intake Form

Please fill in the following form. Starred items are required.

Use N/A when necessary.


*Do you have any of the following?
abdominal pain  arthritis  broken bones  cancer  chronic pain

constipation/diarrhea  decreased range of motion  depression  

diabetes  digestive problems  disc problems  fatigue  headaches

heart attack  high blood pressure  HIV  joint aches  low back pain

low back pain  mid back pain  neck pain  nervous tension  numbness/tingling

osteoporosis  sinus problems  sleep difficulties  sprains  stiffness

stress  stroke  surgery  upper back pain  varicose veins  other  none  

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation & relief of muscular tension. If I experence any pain or discomfort during the  session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment & that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, & that nothing said in the course of the session given should be construed as such. Because massage &/or bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions & answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile & understand that there will be no fault on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session & I will be liable for payment of the scheduled appointment.