Client Intake Form Client Intake Form Please fill this out Consent Form - Client Intake Form Step 1 of 2 50% Name First Last Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Would you like to receive occasional email updates ? Yes No How would you like to receive your future appointment reminders?* Phone call SMS/Text Email Marital Status* Single Married Divorced Widowed Occupation* How did you hear about Aura Metier?Have you ever received any form of Holistic Therapy ? Yes No If Yes, how recently?Have you ever had any Ayurvedic Treatments? Yes No If Yes, how recently?Have you ever received Sound Healing or Vibrational Sound Therapy ? Yes No If Yes, how recently?Have you ever received Professional Thai Yoga Bodywork ? Yes No If Yes, how recently?During Thai Yoga Bodywork what kind of pressure do you prefer ? Light Medium Firm Please indicate which Healing Modalities you have received prior Ayurvedic Medicine Energy Healing Lymphatic Drainage Shamanic Healing Vibrational Sound Therapy Acupuncture Acupressure Chinese Medicine Moxibustion Reflexology Reiki Cupping Pranic Healing Yoga / Qigong Meditation Please indicate your primary reasons for inquiring about Holistic Therapy Promote Relaxation Decrease Stress Restore Cellular Activity Pain Relief Improve Endocrine Function Stimulate Circulation Improve Sleep Pattern Relieve Fatigue PTSD Support Ease Depression Accelerate Pre / Post Surgery Recovery Holistic Living Integrated Cancer Support Alleviate Anxiety Post Grieving Process Chronic Illness Heal Emotional Trauma Lifestyle Change Current Medical HistoryAre you currently under the care of a License Health Care Professional? Yes No If yes, please explain.Are you currently taking any medication? Yes No If Yes, please list any medication, herbs or supplements you are currently taking and why ?Are you pregnant? Yes No If yes, how many weeks?Do you have any Allergies or Sensitivities? (Ex- food, medicine, oils, latex)? Yes No If Yes, please list:Please indicate any medical condition that applies to you: Diabetes Breathing Difficulties High / Low Blood Pressure Anxiety Cancer Lupus Chronic Pain COPD Broken / Fractured Bones Inflammation Hepatitis Swollen Glands Blood Clots Contagious Conditions Pacemaker Osteoporosis Artificial Joints Disc Disorders Depression Seizures Migraines Insomnia Palpitations Open Cuts / Sores Heart Disease Varicose Veins Back Pain PTSD Stiffness/Tingling /Numbness Psychiatric Disorder Blurred Vision Arthritis Reproductive System Conditions Reduced Range Of Movement Aneurysm Irritability Pelvic Pain Chronic Sinus TMJ Nerve Disorders Muscular Disorders Sensitivity To Sound HIV Pneumonia Kidney / Bladder Conditions Stroke Strains / Sprains Fatigue Anemia Stress Grief/ Loss check all that applyDo you currently smoke? Yes No If yes, what do you smoke? Tobacco Marijuana check all that applyHow often? Daily Weekly Occasionally check all that applyDo you drink Alcohol? Yes No If yes, how often? Daily Weekly Occasionally check all that applyDo you currently use any Addictive or Habitual Substances ? Yes No If Yes, please list:Prior Medical HistoryHave you suffered from any physical trauma or emotional verbal abuse? Yes No If Yes, please describe:Did you recently suffer from an acute injury? Yes No If Yes, please describe:Have you had any prior surgery? Yes No If Yes, please describe:Have you been hospitalized? Yes No If Yes, please describe:Have you ever been hospitalized? Yes No If Yes, please describe:Briefly explain, if there is anything else you want to share about your health history that would be useful information for your practitioner to know ?All useful information will be used in creating a plan for an effective treatment session.Our sessions are on a massage table. Do you have any difficulty lying on your back, stomach or side ? Yes No If Yes, please explain:Do you have a particular area of concern ? Yes No If Yes, please explain:Please specify any particular areas you may want the practitioner to concentrate on during treatment?Are you sensitive to gentle touch ? Yes No If Yes, please explain:What are your expectations for the desired treatment ?What are your expected goals for long term wellness ?SignatureToday´s date MM slash DD slash YYYY
