First Name *

Last Name *

Date of birth *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

How did you hear about Wandering Bear Wellness? *

What are you goals for receiving work from Wandering Bear Wellness? *

What have you tried in the past to alleviate your concerns? *

Why is working with Wandering Bear Wellness the right approach for you at this time? *

2. Onset of discomfort/pain *

1. Areas of discomfort/pain *

3. Rate of Pain *

Very little 1

2

3

4

5 Very Painful

5. At what time of day is the pain at its worse? *

Morning

Afternoon

Evening

During Sleep

4. Frequency on Pain *

Constant

At Rest

With Activity

Off/On

6. Have you ever injured this area before? (explain) *

7. Have you ever been in an accident (automobile, work, falls, etc.) ? *

8. List all related treatments received for this injury

9. Is there anything you do that creates, increases or decreases pain?

10. What are the physical duties required of your occupation? *

Do you have any allergies? What are they? *

11.Are you currently seeing any other healthcare professional? *

How long/how many sessions do you think this issue will take to resolve? *

How much water do you drink per day? *

What is the source of the water you drink? *

On avg. How many hours do you sleep per night? *

What movement practices do you have? *

If you going through the Rolfing 10-Series? Would you be interested in documenting your progress with before-and-after pictures?

Would you be open you other services to help you reach your goals? *

Please check any symptoms that apply: Do you have any of the following

Blood Clots (Legs or Lungs)

Cancer

Pinched Nerve

Anxiety/Depression

Difficulty Sleeping

Disordered Eating

Warts, Rashes

Tuberculosis

Hepatitis

Shortness of Breath

Arthritis

Fibromyalgia

Easily Angered

Digestive Problems

Other Skin Infections

Muscle Spasms

Currently Pregnant

Recent Childbirth

IUD

Herniated/Bulging/ Ruptured Disks

Suicidal Tendencies

Low Energy

Seizures

Sciatic Pain

AIDS /HIV

Constipation/ Loose Stool

Osteoporosis

Diabetes

Client information are confidential and written authorization is required to release any information. Do to the nature of the work and the need for the full time of the session any arrivals 15 minutes or more late may be subjected to cancelled session and charge for the full price. 24 hour cancellation notice is required, and you will be charge full price if missed. You will have a consultation with your therapist to discuss the session. I understand the purpose of Structural Integration is to align and lengthen the body on it's center line and in space. Alignment occurs through a series of physical contacts, bodycentered education, and movement training. Structural Integration is a type of body work focusing on the fascia. Fascia is the connective tissue that surrounds muscle. I understand Wandering Bear Wellness is not involved with the treatment of disease of any kind; nor does it substitute for medical diagnosis or treatment when such attention is deemed necessary by a licensed physician. Nothing said or done by Wandering Bear Wellness should be misconstrued as such. In addition, I understand that any relief of physical or emotional symptoms is coincidental in the centering of the physical body and not the direct aim of Structural Integration. Wandering Bear Wellness does not bear any responsibility for any medical or emotional condition occurring while receiving, but otherwise not related to Structural Integration. I understand it is necessary for my practitioner, to touch my body in an appropriate manner in order to assist me in my Structural Integration experience. I give Wandering Bear Wellness my permission and consent to physically assist my body in the Structural Integration session. I further understand that I may, at any time, revoke such permission and consent, and can choose to discontinue the session and any further Structural Integration appointments. I understand that revocation of my involvement in Structural Integration does not release me from the cancellation policy. I agree to inform my Practioner at any point if I feel discomfort or pain during the session. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health have status. By pressing summit, I agree to the policy and client agreement above. *

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