Client Intake Form

Hello and thank you for booking a bodywork session with me, I'm looking forward to working with you!

Before our first session, please take a moment to fill out this form and share any relevant history and information. Submissions through this form are HIPPA compliant.

~Nick Wagner, CMT, RCST

1) Musculoskeletal

Including muscles, joints, skeletal alignment, etc.

2) Cranial & Head

Including migraines, sensitivity, TMJ, etc.

3) Cardiovascular & Respiratory

Including family history.

4) Nervous System

Including sensory, motor, and regulation.

5) Immune System

Including auto-immune. If you have any active skin infections, please let me know beforehand.

6) Genetic

Including family history.

7) Mental Health

Please indicate yes/no if you have experienced trauma. You may share as much or as little as you'd like.

8) Reproductive Health

Including current conditions as well as a full history of pregnancy and birth if applicable.

9) Current Medications

10) Surgeries & Major Accidents/Injuries

Please list all major injuries and/or operations with estimated dates.

11) Allergies

Emergency Contact *

Name and phone number.

Client Information *

First name

Last name

Today's Date

Month

Day

Year