Intake Form Please enable JavaScript in your browser to complete this form.Name *Age *Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOccupation *Height *Weight *Email *Phone *Describe any chronic pain/tension. For how long? *Is your pain/tension worse in the morning or evening? *Does your work or any other activity increase your pain/tension? *Current Medical Issues & Treatments: *Past Medical Issues & Treatments: *If you currently under the care of a physician, what are you being treated for? *If you currently under the care of a chiropractor, what are you being treated for? *If you currently under the care of an alternative medicine practitioner, what are you being treated for? *Please list any medications, vitamins, & supplements you are currently taking: *Please check any of the following that apply to you (in past or currently):Heart ProblemsHigh Blood PressureBlood ClotsPacemakerDiabetesNeurological ProblemsEpilepsy / SeizuresArthritisOsteoarthritisDisc ProblemsPregnancyAccidents / InjuriesSurgeryDizzinessBack ProblemsSpinal ProblemsVaricose VeinsJoint ProblemsMajor Illness / DiseaseHeadachesRecent Breaks / SprainsHow frequently and for how long do you exercise? What do you do for physical activity? Include sports, yoga, gardening, etc. *Consent for Thai Bodywork Treatment *YesNoI understand that the purpose of Thai Bodywork is for relaxation and that it is not meant to diagnose or treat any illness, disease or any other physical or mental disorder, injury or condition. I have informed my Thai Bodywork practitioner (Clare Sente) about my state of health and any recommendations and restrictions on the part of my medical doctor or therapist insofar as bodywork is concerned.MessageSubmit
