About
Yoga
Bodywork
Contact
About
Yoga
Bodywork
Contact
breathe. move. be well.
New Clients
N
ew Client Intake
Contact Information
*
First Name
Last Name
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email Address
*
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Personal Information
Preferred Pronouns
She/Her
He/Him
They/Them
Date of Birth
*
MM
DD
YYYY
Who may I thank for your referral? / How did you hear about me?
*
Of the following, select which best describes how you spend your time
Full-Time
Part-Time
Student
Office
Parent
Artist
Service
Trade
Retired
Military
Other
How many hours per week?
0 to 20 hours
20 to 40 hours
40 to 50 hours
50 to 60 hours
60 to 70 hours
Over 70 hours
Of the following, select which best fits your day-to-day activities
Mostly sitting
Mostly standing
Mostly walking
Computer
Telephone
Light labor
Moderate labor
Heavy labor
Repetitive
Sedentary
Difficult
Enjoyable
Relaxed
Stressful
How often do you exercise and/or participate in physical activity?
*
Never
Less than 1 hour a week
Between 1 and 2 hours a week
Between 3 and 4 hours a week
Between 5 and 6 hours a week
More than 7 hours a week
Pain History
What is the reason for your visit?
Relaxation
Acute pain
Chronic pain
Sports injury
Work injury
Stress
Other
How long have you had this condition?
One week or less
More than one week but less than one month
More than one month
What caused this condition?
Unknown origin
After a fall
After a poor nights sleep
After lifting an object
After reaching or overarching
After performing household chores
After sitting in one place for too long
Associated with prolonged or chronic illness
Other
Where do you feel discomfort?
Head
Jaw
Neck
Upper back
Mid back
Low back
Chest
Shoulder(s)
Upper Arm(s)
Elbow(s)
Lower Arm(s)
Hand(s)
Abdomen
Hip(s)
Upper leg(s)
Knee(s)
Lower leg(s)
Ankle(s)
Foot/feet
Other
Describe the quality of discomfort.
Aching
Annoying
Burning
Deep
Dull
Heavy
Intolerable
Numbness
Pulling
Sharp
Shock-like
Shooting
Stabbing
Stiffness
Throbbing
Tingling
Other
Describe the onset of discomfort.
Gradual
Subtle
Sudden
Spontaneous
Traumatic
Unknown
Describe the level of discomfort.
Mild
Mild to moderate
Moderate
Moderate to severe
Severe
Rate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe.
1
2
3
4
5
6
7
8
9
10
How often do you feel this discomfort?
Constant
Frequent
Intermittent
On and off
Random
Recurring
List any medications you are currently taking.
List any known allergies.
Health History
Musculoskeletal
Bone or joint disease
Tendonitis/Bursitis
Arthritis/Gout
Jaw Pain (TMJ)
Lupus
Spinal Problems
Migraines/Headaches
Osteoporosis
N/A
Circulatory
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
N/A
Respiratory
Breathing Difficulty/Asthma
Emphysema
Allergies
Sinus Problems
N/A
Nervous System
Shingles
Numbness/Tingling
Pinched Nerve
Chronic Pain
Paralysis
Multiple Sclerosis
Parkinson’s Disease
N/A
Reproductive
Pregnant
Ovarian/Menstrual
Prostate
N/A
If pregnant, how many weeks? Any additional information you prefer to share?
Skin
Allergies
Rashes
Cosmetic Surgery
Athlete’s Foot
Herpes/Cold Sores
N/A
Digestive
Irritable Bowel Syndrome
Bladder/Kidney Ailment
Colitis
Crohn’s Disease
Ulcers
Indigestion/Heartburn
N/A
Psychological
Anxiety/Stress Syndrome
Depression
N/A
Other
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
N/A
Feel free to provide information on any other medical condition(s) not listed that may influence your session.
Informed Consent
It is my choice to receive yoga instruction and/or bodywork. I am aware of the benefits and risks of yoga and/or bodywork and give my consent to receive yoga/bodywork. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that yoga and/or bodywork is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that Valerie Penrose, Yoga & Bodywork has provided this form as a reference and is not held liable for any services provided. COVID-19: I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive yoga/massage from this practitioner. I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.
Contract for Care
I will make sound choices regarding my sessions’ plan based upon the information provided by my yoga instructor/bodyworker. I agree to communicate with my practitioner any time I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of their skills and knowledge.
Policy Agreement
I have read the outlined policies (https://www.valeriepenrose.com/policies/), understand and agree to comply with the professional yoga and bodywork standards set by Valerie Penrose, Yoga & Bodywork.
Client Signature
*
Date
*
MM
DD
YYYY
Thank you!
