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First Visit Form

First Visit FormDanielle Hobeika2023-03-15T23:23:19+00:00

"*" indicates required fields

General Patient Information

Address*
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Pain & Symptoms

The form is very important in your evaluation process. Please fill it out as specifically as possible to provide us with a clear picture of your present pain and functional status.

Past Treatment & Medical History

Have you ever received any of the following treatments for this condition?
Check the box if you have had any of the following medical conditions*
Medication / For treatment of / Amount per day / Effectiveness
Do you experience any of the following do you experience on a DAILY basis?*
Do you experience any of the following do you experience on a WEEKLY basis?*
Do you experience any of the following do you experience on a MONTHLY basis?*

Exercise & Sleep

Daily Activities

Please estimate the amount of time, on average, you spend in each of the following activities per day.
Activity / Tolerance (minutes/hours)

Functional Ability

Activity / How Often or Duration / By When

Practices & Policies

Consent*
Massage, bodywork and somatic therapy practices are designed to promote and maintain the health and well-being of the client and do not include the diagnosis or treatment of illness, disease, impairment or disability. If I experience pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. Because massage, bodywork and somatic therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all my known medical conditions and will keep the therapist updated as to any changes in my medical condition.

To the best of my knowledge, the information I have provided is accurate and true. I understand that I am an active participant in my healing and it is my responsibility to provide accurate and timely feedback to my therapist regarding my response to treatment. I understand that I am in full control of my treatment and have the right to halt any technique at any time by asking my therapist to ease up or stop completely, which will be complied with immediately. I am aware that ‘tissue memory’ may occur during and after treatment and that I am free to express emotions (crying, laughter, sounds, anger, movement, etc.) as my body needs, while my therapist keeps me safe during these normal responses. I am also aware that pain symptoms may increase during and after treatment as part of the healing process.
Cancellation Policy*
CANCELLATION POLICY is 24-hour Advanced Notice in CA and NJ, and 48 hours in NY. Since your appointment time is set aside specifically for you, we require that all clients extend a courteous 24 or 48 hour cancellation notice to change or cancel any appointment. If less than 24 or 48 hour notice is given, the full session fee is due immediately. All Intensive Treatments are reserved and paid for in advance and are nonrefundable. If a cancellation is made to an Intensive schedule, the remaining hours may be used in future visits within the next 12 months.
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