Before your first session, your practionner will contact you by email and send you a form to fill. This form is reproduced below and you can also print this page, kindly fill it out to the best of your knowledge and bring it along with you at your first visit.
(All information is strictly confidential and is for information and safety purposes)
General information
| ||
Age | Gender | |
Email | Phone number | |
Occupation | ||
Emergency contact person | Emergency Phone number | |
Referred By |
Have you had massages, bodywork/treatments before? | YesNo |
Are you currently under a physician's care? | YesNo |
Do you have any recent injuries? | YesNo |
If so, please explain: | |
Are you currently taking any medication? | YesNo |
If so, please explain: | |
For your safety, our therapists must be aware of all medical conditions for which you have been diagnosed. Massages, bodywork/treatments may impact your health.
Please check any of the following medical conditions/symptoms that you have experienced in the last year
| □ □ □ □ □ □ □ □ □ □ | Cardiovascular Disease High Blood Pressure Stroke Varicose Veins Phlebitis/Thrombosis Repetitive Strain Injury joint problem Disc Problems Sciatica Respiratory /lung condition | □ □ □ □ □ □ □ □ □ | Carpel Tunnel Arthritis Asthma Diabetes Pregnancy Possibility of pregnancy Allergies Surgery / Hospitalization | □ □ □ □ □ □ □ □ □ | Hypertension Migraines Anemia Fibromyalgia Cancer or Tumors Kidney or liver disease Immunity Related Disorder Depression Insomnia |
Disclaimer
Somatic Movement and Shiatsu do not intend to diagnose, cure any physical or mental ailment, and should not replace consultation with your physician nor habitual treatment.
Anne Cousin is not licensed to diagnose or prescribe any medical conditions, medicines or diseases and information contained on themovingtouch.com is not intended to be substituted for such.
Anne Cousin makes no claims to heal you of any medical or emotional condition you may have. Always check with your primary health care physician before trying a new therapy.
Information provided on this website is done so with the intention of sharing knowledge of bodywork and massage.
Please note that Shiatsu and Somatic Movement are body treatments of entirely no-sexual nature and that any inappropriate behavior will be handled in the most severe way, including legal prosecution.
Please read and sign
I verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety and information purposes and will be kept strictly confidential.
Date | Signature |