Karuna Five Element Shiatsu

Clinic - Client Intake Form

Karuna Center for Yoga and Healing Arts

25 Main St. Northampton MA 01060

413-584-5054

Please take the time to fill out this questionnaire carefully. The information you provide will assist in formulating a complete health profile for you. All your answers are absolutely confidential. If you have any questions, please ask.

Name: ______Date: ______

Address: ______

City: ______State: ______Zip: ______

Home phone: ______Work phone: ______

Mobile phone: ______email: ______

Date of birth: ______Age: ______Marital status: ______

Occupation: ______

Physician: ______phone: ______

In Emergency Notify: ______phone: ______

What would you like to focus on today?

______

Do you like firm or light pressure?______

Do you have any areas of pain and/or stiffness?

______

Do you have any injuries?

______

Have you had any operations? Please explain.

______

Significant trauma (physical or emotional)

______

Allergies (chemical, environment, food, drugs, etc.)

______

Medications (names & dosages) please attach an additional page if necessary

______

Vitamins/Supplements/Herbs

______

Exercise

(days per week – length of workout – type of activity)

______

Diet

(meals per day – snacks – caffeinated drinks – alcohol per week)

______

What makes your condition better? (rest, movement, heat, cold, fresh air, eating, crying,…)

______

______

______

______

What makes your condition worse? (stress, fatigue, hunger, heat, certain foods, dampness,…)

______

______

______

______

Shiatsu Consent to Treatment

I hereby request and consent to the performance of shiatsu treatments and other Oriental medicine procedures on me (or on the patient named below, for which I am legally responsible) by the below named shiatsu practitioner.

I understand that methods or treatments may include but are not limited to shiatsu, moxibustion, cupping, Tui Na (Chinese massage), GuaSha and application of linaments.

I have been informed that I have a right to refuse any form of treatment. I have read, or have head read to me the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I also understand there is always a possibility of an unexpected complication and I understand that no guarantee can be made concerning the results of treatment. I intend this consent form to cover the entire course or treatment for my present condition and for any further condition(s) for which I seek treatment. ______(initials)

I agree to pay the full charge for any missed or forgotten appointments without 24-hour notice of cancellation ______(initials)

Patient’s name: ______

Patient’s signature: ______

Date signed: ______

Are you pregnant?: ______

Name of shiatsu practitioner: ______

Karuna Center for Yoga and Healing Arts

25 Main St. Northampton MA 01060

413-584-5054