top of page
Attune and Bloom Bodywork
MENU
Close
Home
Welcome
Service List
First Time Client
Book Online
Plans & Pricing
First name
*
Last name
*
Preferred Name
Email
*
Phone
*
Birthday
*
Month
Day
Year
Multi-line address
Country/Region
*
Address
*
City
*
Zip / Postal code
*
How did you hear about us/who referred you?
What sex were you assigned at birth?
Male
Female
Prefer not to answer
What pronouns do you prefer?
He/Him
She/Her
They/Them
Do you need disability access?
If yes, please give detailed information on your specific needs
Please list any allergies
Emergency Contact Name
*
Emergency Contact Phone
*
Relation to Emergency Contact
Primary Care physician name
Primary Care contact information
Do you have a referral from a physician/ will be requesting superbills?
Preferred method/s of contact
Call
Text
Email
What times/ dates work best for me to contact you?
Do you have any mental health diagnosis? If so, please list/explain
Rate the current stress level in your life
Low
Medium
High
Select any stressors you are presently or have recently experienced
Major Illness or Accident
Death of loved one/ friend/ family
Relationship challenges/ Divorce
Surgery/ Post-op
Pregnancy/ Birth/ Miscarriage
Illness of a close family member or friend
Other
Does your level of mental activity become stressful, distracting, or uncomfortable?
Describe your sleeping habits/ number of hours asleep/ how often you wake
List any medications you are currently taking
List the supplements you are currently taking
Do you have any known autoimmune issues? If yes, please describe
Please select any skin issues that you have experienced or are currently experiencing
Scars
Eczema
Sun damage
Psoriasis
Skin Infections (ex: Warts, Athletes Foot, Impetigo)
Contact Dermatitis
Have you ever had surgery? Please list what you've had done and approximate dates
Do you experience any swelling anywhere in your body? Please describe
Do you experience any pain in specific areas in your body? Please describe
Do you currently use birth control? If yes, list all methods used
Do you experience menstrual periods?
Please list the date of your last menstrual period
Are you currently pregnant?
List dates of past pregnancies
Dates of vaginal births
Dates of C-sections
Select all that have been a part of your life in the last 6 months
International travel
Alcohol
Caffeine
Recreational Drugs
Illness or Infection
Prescription Medication
Select all that are a part of your typical diet
Dairy
Fruits and Vegetables
Meats
Breads/ Gluten
Sugar
Organic
Non-Organic
Please describe your daily hydration and fluid intake
Do you exercise regularly? If yes, describe type and frequency
Do you have a regular spiritual practice?
Do you have supportive connections to friends, family, or community?
What are your overall goals for your upcoming session?
Signature
*
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
*
Month
Day
Year
Submit
bottom of page