Self-Intake form | freedbodyworks-1

Freed Bodyworks

Appointment Self-Intake Form

In order to expedite getting you the table and minimizing discussion in the treatment room, please fill out this quick intake check-in. Your therapist will use this form to ask follow-up questions as needed before the session. Thank you for your cooperation as we figure out how to do bodywork under these new conditions.

First Name

Last Name

Changes in your overall health since last appt:

Changes to your how you use your body since last appt:

What is your goal(s) for today’s session?

Is there anything about your non-physical health that you want your therapist to know?

What areas of your body are experiencing pain or discomfort? Are they typical for your body or new? Do you know any possible causes of the pain/discomfort?

Do you have any concerns about COVID that you would like to discuss with your therapist at the beginning of your appt?

Initials

Date

Thanks for submitting!