Stretch The Exec | The Wellness Brands

CLIENT INTAKE FORM

A premium, on site stretch therapy service designed specifically for executives and corporate leaders to reduce stress, improve mobility and regulate the nervous system.

We bring professional, structured mobility sessions directly into your corporate environment; discreetly, efficiently and results-driven.

First name

Last name

Phone

Email

Birthday

Month

Day

Year

Address/Province

Occupation

Primary Health Care Provider

Emergency Contact

GENERAL AND MEDICAL INFORMATION

Are you currently under the care of a physician? If so, why?

Yes

No

Short answer

Have you ever had a stretch session? If yes, how often? What kind?

Yes

No

Short answer

Are you Pregnant?

Yes

No

High Blood Pressure?

Yes

No

Diabetic? If yes, is your diabetes under control?

Yes

No

Short answer

Broken any bones in the past two years? If which?

Yes

No

Short answer

Cardiac or circulatory issues? If yes, please explain.

Yes

No

Short answer

Have you ever had surgery? If yes, please explain.

Yes

No

Short answer

Do you have any other medical conditions, major accidents or injuries?

Yes

No

Short answer

Current medications? What for?

Yes

No

Short answer

What is your reason or goal for receiving stretch therapy?

Please sign the waiver form below.

CLIENT WAIVER FORM

Please take a moment to read and initial the following information:

Multi choice

I understand that stretch therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation, range of motion and energy flow.

Multi choice

If I experience pain or discomfort during the session, I will immediately inform my practitioner so that pressure can be adjusted to my level of comfort. I will not hold my practitioner responsible for any pain or discomfort I experience during or after the session, nor will I pursue any legal action against the practitioner.

Multi choice

I affirm that I have notified my practitioner of all known medical conditions and injuries and that I am fit to participate in the stretch therapy session.

Multi choice

I agree to inform my practitioner of any changes in my health and medical condition. I understand that there shall be no liability on the instructor’s part should I forget to do so.

Multi choice

I understand that stretch therapy sessions are designed to assist in greater stretch gains and are non-sexual in nature.

Multi choice

I understand that there is a 24-hour cancellation policy. If I am unable to cancel before that time, I will be responsible for the costs associated with that session.

Multi choice

I agree that in the event my insurance refuses payment for any session, I am fully responsible for paying my outstanding balance.

Multi choice

I have been informed, understand and am aware that stretch therapy involves a risk of serious injury. These risks include but are not limited to dizziness, fainting, skeletomuscular injuries, muscular tears, cardiovascular injuries and any other injury resulting from exercise, stretching and body manipulation.

Multi choice

I understand that the services offered today are not a substitute for medical care. I understand that my practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.

INFORMATION AND SUGGESTIONS

Prior to your stretch, please remove jewelry or watches. Pull long hair back with a clip or band.
Please wear loose, long, comfortable clothing that allow for freedom of movement.
Feel free to ask your practitioner any questions before, during, or after the session. Your practitioner is a highly trained professional and will be happy to make you feel informed and comfortable.

ADDITIONAL INFORMATION

Write "N/A" if it doesn't apply.

What are your current issues? For how long?

Have you ever been in an accident, even as a child?

Do you have any major scars? C-section, surgery, etc. If so, where?

Do you have some concerns about breathing? What about during exercise?

Do you have any sleep discomfort? Please describe.

How many hours do you sleep?

What is your quality of sleep on a scale of 1-10? With 10 being complete rest through the night.

What is your stress level on a scale of 1-10? With 10 being extremely stressful.

What do you do to relieve stress?

When was the last time you saw a health professional?

What have they ever told you? What have you worked on with them?

Have you worked with a body worker (i.e.—RMT)? If so, what have they ever told you?

Do you exercise? What do you do and how often?

Do you have a flexibility and mobility program you follow?

Do you have trouble activating certain muscles?

What movements provide discomfort or feel tight?

How many hours do you sit a day?

Do you drink alcohol? How many drinks a week/month/biweekly basis?

Do you feel dehydrated?

How many bottles of water do you drink a day?

What do you feel could be your issue(s)?

What has worked in the past? What hasn’t?

How committed are you in putting in the work to resolve your issues? On a scale of 1-10 (10 being the most committed).

I have read and agree to these policies therein.

By signing this release, I hereby waive and release my practitioner from any and all claims, costs, liability and expense for any injury, loss or damage whether known, anticipated or unanticipated arising from my voluntary participation and purchase of the stretch therapy session and bodywork.

I understand that by signing this document, I am waiving certain rights I or my successors might have to bring a legal action or assert a claim again the practitioner and any of her employers, contractors, agents, volunteers or assigns.

Client's Name:

Client's Signature:

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Parent signature (if under 18 years):

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Today's Date:

Month

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Short answer

1-242-808-8350
Whitney@TheWellnessBrands.com
New Providence, Bahamas

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1-242-808-8350 Whitney@TheWellnessBrands.com New Providence, Bahamas

Join our mailing list

1-242-808-8350
Whitney@TheWellnessBrands.com
New Providence, Bahamas