Water Therapy Intake Form
 
PLEASE PRINT PAGES BELOW. FILL OUT PAGES ONE TO FOUR BEFORE YOU COME AND BRING THEM TO YOUR SESSION. THANK YOU. Click on pdf to download and print pages shown below: AQOASIS INTAKE FORMS.pdf Aquatic Body Work & Therapy Watsu®, Healing Water Dance, Jahara® & Beyond. STATEMENTS OF HEALTH PROFILE & UNDERSTANDING TO BE READ AND SIGNED BEFORE AQUATIC SESSION BEGINS: I understand that a session of any form of Aquatic Bodywork can be powerful and have profound effects on the body and the mind. It is my responsibility to express any needs I may have during the session. (ie: temperature, movement concerns, body contact, toilet needs, hydration etc.) I have stated fully my medical and psychological conditions on the health care intake form (Page 1). I understand that there have been no medical or diagnostic claims made for this session. I understand that receiving a session in any kind of bodywork always involves a slight risk. I willingly accept that risk and hold no one else: practitioner(s) and/or “AqOasis” responsible for anything that happens to me in my session. I am free at anytime to make my needs known and take care of myself. I understand that being held “as is required “ while being floated, can bring up issues that people have about intimacy. It is my responsibility to express any concerns beforehand and communicate during the session if needed. I will give feedback the moment anything is uncomfortable. I will let my practitioner know at anytime if my head, neck, and back do not feel adequately supported. The body arrives at deep levels of relaxation only possible in 92-96 degrees of warm water, therefore it is normal for the tension holding patterns to release. Occasionally, the release may cause momentary discomfort. If I have any concerns if this happens, I will speak with my practitioner to know how to better take care of myself. Page One AqOasis®2008 - 2011 All Rights Reserved. AQOASIS: Aquatic Bodywork & Therapy CLIENT INFORMATION & HEALTH INTAKE FORM Name:_________________________________ Telephone: HM)__________________ Cell)__________________________ WK)_____________________________ Address:__________________________________________________________________ Street Apt City State Zip Code ___________________________ Email Address:__________________________ Drivers License #________________________ ____________ State Exp In Case of Emergency:_________________________________Telephone:______________ Referred by: ________________________________________________________________ General & Medical Information Age:__________ θFemale θMale Date of Birth:_______________________ θYes θNo Have you ever experienced a professional bodywork session? If so, what kinds?____________________________________________________________ θYes θNo Aquatic Bodywork? If so, how recently and where?_________________________________________________ What physical activities do you do regularly?_____________________________________ What relationship do you have with water?_________________________________ θYes θNo Do you experience motion sickness? θYes θNo Do you get ear infections? θYes θNo Do you frequently suffer from stress? What is the source?_________________ θYes θNo Are you pregnant? θYes θNo Have you been in an accident θYes θNo Do you experience headaches? or suffered any injuries in the past 2 yrs? θYes θNo Are you wearing contact lenses? _________________________________ θYes θNo Do you suffer from arthritis? θYes θNo Do you have tension or θYes θNo Do you have high blood pressure? soreness in a specific area?___________ θYes θNo Are you taking medication? θYes θNo Have you had any broken θYes θNo Do you have diabetes? bones in the past 2 years?____________ θYes θNo Do you suffer from joint swelling? θYes θNo Do you have cardiac or θYes θNo Do you have varicose veins? circulatory challenges?_______________ θYes θNo Have you ever had surgery? θYes θNo Do you have back pain?_____ θYes θNo Do you have any contagious diseases? θYes θNo Do you have numbness or θYes θNo Do you have osteoporosis? stabbing pains anywhere?_____________ Page Two AqOasis®2008 - 2011 All Rights Reserved. θYes θNo Do you have any allergies? θYes θNo Are you sensitive to touch or θYes θNo Do you bruise easily? pressure in any area?_________________ θYes θNo Do you have any other medical θYes θNo Do you suffer from epilepsy conditions I should be aware of?_________ or seizures? ________________________ Comments:_________________________________________________________________ Take a moment to carefully read the following and sign below. If you have a specific medical condition or specific symptoms, aquatic bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that full payment for a session of aquatic bodywork is due before the session. I understand that each session is scheduled just for me and that a (24) twenty-four hour notice of cancellation is required or a $45.00 fee will be due and billed. Also, if I do not show up for a session scheduled I am required to pay in full for the session scheduled. All personal belongings are the exclusive responsibility of the client and not any practitioner or AqOasis. I understand that the aquatic bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain, discomfort, or motion sickness during this session, I will immediately inform the practitioner so that the pressure, strokes, and/or movement may be adjusted to my level of comfort. I further understand that aquatic bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that aquatic bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe, or treat a physical or mental illness, and that nothing said in the course of the sessions given should be construed as such. Because aquatic bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part or that os AqOasis. It is also understood that any illicit or suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Client Signature:____________________________________________Date:_____________ Consent to Treatment of Minor: By my signature below, I hereby authorize and permit: Practitioner: ___________________________________ to administer aquatic bodywork therapy techniques to my child or dependent, as they deem necessary. _______________________________________________________Date: _______________ Signature of Parent, Guardian or Authorized Care Provider: Page Three AqOasis®2008 - 2011 All Rights Reserved. I HAVE READ AND AGREED TO THE ATTACHED STATEMENT ON PAGES ONE, TWO AND THREE. I AM LISTING BELOW ANY CONDITIONS THAT MIGHT BE AFFECTED BY A SESSION. Please discuss with your practitioner any conditions listed below before going into the water: • Conditions that might be affected by stretching and movement: • Conditions that might be affected by being in warm water: • Psychological conditions or trauma affected by being held: • Susceptibility to motion sickness: • Previous experience with therapeutic land-based bodywork: • Previous experience of aquatic bodywork: • Expectations or concerns; can you swim? (Yes) (No). Have you had ANY negative experience in the water, such as a near drowning? (Yes) (No). Explain:__________________________________________________________________________________ _________________________________________________________________________________________ Date: ______/______/________ PRINT NAME: ____________________________________________________________________________ SIGNATURE: _____________________________________________________________________________ Page Four AqOasis®2008 - 2011 All Rights Reserved. Intake Forms_files/AQOASIS%20INTAKE%20FORMS-1.pdfshapeimage_2_link_0