Upon Booking 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.

 


 

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?

 

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 Xrays 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 to develop a personal treatment plan for you 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.

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