Somatic Movement Therapy, Bodywork, and Massage
Client Information for Maryrose Dolezal
Today’s Date: __________________ Date of Birth:_________________
Name & Preferred Pronoun: __________________________________________
(what you would like me to call you)
________________________________________________________________
(legal name)
Address: _________________________________________________________
City: ________________________ State : ________ Zip : _________________
Cell phone: _____________________________________________________
Is it OK for me to leave a message at cell phone number? Circle: YES or NO
Alternative phone: ________________________________ Circle: Home or Work
Is it OK for me to leave a message at home/work number? Circle YES or NO
E-mail____________________________________________________________
Emergency Contact Name: ___________________________________________
Relationship to You:___________________________________________
Phone Number:_______________________________________________
Referred by: _______________________________________________________
Occupation:
Description of family & community:
Description of cultural identity:
Briefly describe what you want to gain from this work (your intentions):
What is your major condition you want to improve?
Has there been a medical diagnosis? ________________________________
If so, by whom and when? ________________________________________________________________________________________________________________________________________________________________________________________________
Please list other therapies you have received or are receiving:
Please list any surgeries, accidents, major illness or trauma with approximate dates:
Please list any medications and nutritional supplements that you are taking:
Describe your nutrition/diet:
Describe your exercise &/or meditation routine, including frequency:
How much sleep do you get on average in the last month? Last year?
How often do you have a bowel movement?
What is your daily water intake?
Any life transitions or big decisions taking place in near past or future?
Do you have allergies to nuts? Y N
Other Allergies:_________________________
Do you wear contact lenses? Y N
Do you wear dentures? Y N
Do you have arthritis? Y N
Varicose veins? Y N
Blood clots ? Y N
Heart problems? Y N
High Blood Pressure? Y N
Infectious skin conditions? Y N
Anything else you would like me to know about you as a client: