New Client Health Intake Form

1. Date:

Apr 7th, 2025

2. Client Name:

Kelly Stone

3. Date of Birth:

Oct 27th, 1973

4. Phone:

(505) 918-5666

5. Address:

1044 19 th Street NW

6. Email:

kmstone08@gmail.com

7. Physician/Health-care Provider Name:

Claire Melgaard, CNP

8. Physician/Health-care Provider Phone:

(505) 771-5214

9. Emergency Contact Name:

Jean Jacobson

10. Emergency Contact Phone:

(505) 241-9059

11. How did your hear about Jen & Wild Sage Bodywork?

Jami Porter Lara

12. Have you ever received professional massage/bodywork before?

Yes

13. How many of the following bodywork modalities have you received in the past?

Craniosacral Therapy, Visceral Work

14. What are your goals & expected outcomes for receiving massage/bodywork?

I would like to work on and receive some relief from stiffness and soreness in my neck, shoulders, and hips.

15. List the medications you currently take & what condition they are for:

Losartan 25mg

16. Please select any of the health related conditions that you have now or have had in the past:

Muscle or Joint Pain/Stiffness , Headaches/Migraines, Dizziness/vertigo/ringing in ears, Jaw Pain/Clicking/Popping

17. Do you wear any of the following?

None of the above

18. Have you had any injuries, car accidents, falls or surgeries in the past. If yes, please list the year that they occurred.

ACL replacement/meniscus repair - left knee

19. List and prioritize your biggest areas of concern. Please include your current symptoms/issues in these areas:

Neck pain, upper trap soreness, jaw pain.

19. Do these symptoms interfere with your activities of daily living (ie sleep, exercise, work, childcare)?

Yes

20. Please check all areas of the body in which you are willing to have bodywork:

Neck, including front and sides, Head/Back of Neck/Shoulders, Midback, Low back, Back of pelvis, including hips, Gluteals, tailbone & sits bones areas., Legs , Arms, Hands/Feet, Front of Pelvis, including lower abdomen & near the groin area , Abdomen, including upper and lower sections, superficial & deeper layers., Ribcage area, including front of ribs & breastbone (sternum), sides and back of ribs., Armpit Area, Upper Chest Muscles (below the collar bones and above breast tissue), Breasts (consent form will also need to be filled out), Inside the mouth/TMJ massage

21. Are you interested in receiving Breast/Full Chest Massage? (Please note that an additional consent form will need to be filled out to receive this service)

Need more info before I decide

Consent to Treat- Please check ALL boxes below to show you understand the following:

I agree to tell Jen if I have pain during my session so that she can change technique accordingly, I understand that bodywork does not substitute a medical exam, diagnosis or treatment, I understand that Jen, as an MT, is not qualified to diagnose or prescribe for any illness, I affirm that I have a provided all known medical conditions & answered all questions honestly, I agree to immediately update Jen of any changes to my medical profile , If I fail to update Jen of these profile changes, there shall be no liability on Jen's part, I agree that any sexually suggestive behavior will result in ending the session immediately, Understanding all of the above, I give my consent to receive care

Office Policies- Please check ALL boxes below to show you understand the following:

Payment is due before or at the time of service. , Accepted forms of payment: cash, check, credit card, Paypal, Venmo. $35 fee for bounced checks, 24 hours notice is required for cancelations, except in cases of emergency , 50% of the scheduled session fee is due for late cancelations (within 24 hours) or no shows , If you have any COVID related symptoms, please cancel your session with Jen with NO cancelation fee, Jen does not take insurance claims, but can supply you with a detailed receipt for reimbursement

Write your full name below for signature

Kelly Stone

Enter today's date

3/28/25

I give consent as parent or guardian for my child, under the age of 18, to receive bodywork from Jennifer Gibson MT of Wild Sage Bodywork. Signature Below.

I understand that all minors under the age of 16 must be accompanied by a parent or guardian during their session.

Yes