Health Declaration

Please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

Do you have any specific areas of concern?

Yes

Are you suffering from a medical condition, illness or injury?

Yes

If you answered yes to any of the questions above, please supply additional information.

Have you had any muscular/skeletal related surgeries?

Yes

If yes, please provide a brief description and date of the surgery in the space below.

I declare that the info I’ve provided is accurate and complete.

I understand that it is my responsibility to inform the therapist of any and all medical changes and concerns. And am required to inform them at any point in time during the session if they are doing something I am uncomfortable with. And/Or would like the session to conclude with no reimbursement.

By initialing below, I am giving my consent to treatment as well as agreeing to the terms presented above.