Tui Na Intake Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you a student? *

Yes

No

Have you had professional bodywork before? *

Yes

No

Do you have any difficulty lying on your front, back, or side? *

Yes

No

Do you have any allergies to oils, lotions, or ointments?

Yes

No

Do you have sensitive skin? *

Yes

No

Please check if you are you wearing any of the following: *

Contact lenses

Dentures

Hearing aids

Hair piece

None of the above

Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? *

Yes

No

Do you have any particular goals in mind for this tui na sessions? *

Yes

No

Have you ever had any surgery or hospitalization? *

Yes

No

Have you ever been involved in an injury or auto accident? *

Yes

No

Are you currently taking any medications? *

Yes

No

Are you currently under medical supervision? *

Yes

No

Are you pregnant?

Yes

No

Please check any conditions listed below that applies to you: *

Skin Condition (i.e rash, acne, eczema)

Open Sores or Wounds

Bruise Easily

Recent Accident or Injury

Recent Fracture

Recent Surgery

Artificial Joint

Sprains/Strains

Current Fever

Swollen Glands

Allergies/sensitivity

Heart Condition

High or Low Blood Pressure

Circulatory Disorder

Varicose Veins

Atherosclerosis

Osteoporosis

Epilepsy

Headaches/Migraines

Cancer

Diabetes

Decreased Sensation

Back/Neck Problems

Fibromyalgia

Carpal Tunnel Syndrome

TMJ/Jaw Pain

Tennis Elbow

Phlebitis

Hepatitis (A, B, C, other)

Stroke

Scoliosis

Seizures

Constipation/Diarrhea

Diverticulitis

Depression, Panic Disorder, other Psych Condition

HIV/AIDS

Lupus

Deep Vein Thrombosis/Blood Clots

Joint Disorder/Rheumatoid Arthritis/Osteoarthritis

Tendonitis

Chemical Dependency (Alcohol/Drugs)

None of the above

Have you flown on a plane recently? *

Yes

No

Please read and type your name below to acknowledge that you have read and understand the following: *

1. I am aware that the Tui Na session will be done clothed 2. I understand that my feedback is an essential element in my treatment, therefore if at any time I should become uncomfortable during the session, I may bring it my practitioner's attention. 3. If I am unable to keep an appointment, I understand that a 24-hour notice is required; otherwise I will be charged the cost of the session by whatever payment method is on file. If I decline to have payment on file, I am required to pay the 50% deposit each time I book an appointment 4. It is my responsibility to explain and discuss all physical conditions with my Tui Na practitioner so that (s)he may do his/her job. The Practitioner may diagnose conditions according to Traditional Chinese Medicine. 5. The Tui Na practitioner does not do spinal manipulations. Tui Na is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for any ailment that you have. 6. I have read and I fully understand this form in its entirety. If at any time there are changes in the information given or in my condition, I will notify my practitioner before receiving additional bodywork and that there shall be no liability on the practitioner’s part if I fail to do so. 7. All information contained on my Health History, as well as anything shared verbally within any treatment, will remain confidential between the Tui Na practitioner and myself unless I give consent to share this with other professionals, or if the law requires.

First Name

Last Name