Before your first Appointment....

Once you have scheduled your first appointment, please copy this questionnaire into a new email and send it to me at bearhawkmassage@gmail.com before your scheduled appointment.  This will allow me to plan treatment before your arrival and save you some table time. Also, be sure to look over the Covid19 information page here on the website so that you can be informed of new information and necessary precautions.

Initial Visit Questionnaire

Name:

Today’s Date:

Date of First Appointment:

Address:

City:

State:

Zip Code:

Date of Birth:

Height:                  Weight:            

Best Phone:

Alternate Phone:

Email:

Can messages be left for you?

   If so, would you prefer voice or email?

Were you referred by someone?  

If so, who?

How would you describe your physical condition?

What type of treatment are you seeking?

What are your short and long-term goals for treatment?

S:

L:

Have you been vaccinated against Covid19?

Are you experiencing discomfort/pain now?  

If so, please describe.

Have you seen other therapists or practitioners for this condition?

   If so, who?

Have you had X-rays or MRIs taken?

   If so, by whom and for what purpose?

Any sensitivities/allergies to substances or chemicals?

Additional Comments (Tell me a little about how you live your life.):

This brief questionnaire is designed to help assess your physical condition and develop a personal treatment plan based on your particular needs and condition. The more honest and thorough you are, the more accurate the treatment plan will be.

At this office, we are committed to providing you with high-quality care and to forming a relationship with you based on trust. Please be assured that your information will be kept private and confidential. As we are providing health care, both ongoing and preventative, we will maintain copies of your treatment history, current condition, treatment plan, and all treatments given. Whether this information is stored in written form or on a computer, every effort will be made to ensure your privacy. This information will not be shared with anyone without your expressed permission unless we are required to do so by law.

Should you need to reach me with any questions:

I’d love to discuss how I can best help you live comfortably and effectively.

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I can be reached by voice or text at  617-331-3133 and by email at bearhawkmassage@gmail.com.

These will go directly to my phone and are the most efficient way to reach me.

Please let me know whether you prefer to be contacted by voice, text, or email.