Intake Form

Thank you for making The Physiotherapy Institute a part of your wellness lifestyle. Please take a moment to fill out the intake form so that we may best customize your session.

* Indicates required field

Name *

First

Last

Date of Birth *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Referred by (Name, Flyer, Website, Social Media, etc. ) *

Are you currently seeing a health care professional? *

Yes No

Are you currently taking any prescribed medicines? If yes, please explain. *

Are you pregnant? If yes, how many weeks and please describe any musculoskeletal discomfort you are experiencing? *

List any major accidents or surgeries (including dates) *

Have you had professional massage and bodywork before? *

Yes No

Reason for initial visit and result you would like from your bodywork session? *

Do you experience headaches? *

Neck pain or discomfort? *

Shoulder pain or discomfort? *

Midback or pain between shoulder blades? *

Lowback pain and discomfort? *

Arm/Elbow pain and discomfort? *

Wrist/Hand pain and discomfort? *

Hip pain and discomfort? *

Knee pain and discomfort? *

Ankle/Foot pain and discomfort? *

It is my choice to receive therapeutic massage and bodywork as a form of therapy. I understand that treatment given is designed to address the care and prevention of myofascial pain and musculoskeletal dysfunction. I am aware of the benefits and risks of massage and bodywork and give my consent to participate. I understand that there is no implied or stated guarantee of success or effectiveness of individual techniques or series of appointments. I acknowledge that massage and bodywork therapy 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 my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. Treatments may be covered by extended health care plans such as Flex Spend Accounts or Health Savings Accounts. I understand that it is my responsibility to confirm the exact details of my coverage. *

By checking this box and submitting this form you are electronically signing and agreeing to the terms of service.

Submit

Thank you for making The Physiotherapy Institute a part of your wellness lifestyle. Please take a moment to fill out the intake form so that we may best customize your session.

BSc Health Education Texas Woman's University
TX Approved Massage Therapy CE Provider #CE2077
TX Licensed Massage Therapist #MT034633
Cooper Institute Certified Personal Trainer

Phone: 214.235.8441
Email: p [email protected]

Thank you for making The Physiotherapy Institute a part of your wellness lifestyle. Please take a moment to fill out the intake form so that we may best customize your session.

BSc Health Education Texas Woman's UniversityTX Approved Massage Therapy CE Provider #CE2077TX Licensed Massage Therapist #MT034633Cooper Institute Certified Personal Trainer

Phone: 214.235.8441​ Email: p[email protected]

BSc Health Education Texas Woman's University
TX Approved Massage Therapy CE Provider #CE2077
TX Licensed Massage Therapist #MT034633
Cooper Institute Certified Personal Trainer

Phone: 214.235.8441
Email: p [email protected]