JASON RAY BROWN
Confidential Intake Form
1. PERSONAL INFORMATION
Indicates required field
Date of Birth (MM/DD/YYYY)
2. EMERGENCY CONTACT INFORMATION
3. GENERAL QUESTIONS
Please list any allergies to oils, lotions or ointments.
I usually use Biotone lotion, which is hypoallergenic. It contains coconut oil, apricot oil, grapeseed oil and sesame oil. If you have allergies to any of the above ingredients I also have avocado oil that I can use.
Do you have sensitive skin? If so please explain.
Does your job or leisure activity require you to sit for long periods of time?
Yes - I tend to sit a lot throughout the day
Not really - I'm pretty active throughout the day
It varies - some days I sit a lot and some days I move a lot
Do you perform a lot of repetitive movements in your work or leisure activity? If yes, please describe.
What kind of exercise to you participate in?
Other Exercise (Not Listed)
None of the Above
How often do you exercise?
5-6x per week
3-4x per week
1-2x per week
1-2x per month
4. REASONS FOR SEEKING PRIVATE YOGA AND/OR MASSAGE THERAPY
Why are you seeking private yoga instruction and/or massage therapy at this time? (Check all that apply)
To reduce stress and promote relaxation
To maintain overall well-being and prevent the build-up of stress and physical tension (i.e., maintenance massage)
To increase strength and stability
To increase range of motion and flexibility
To improve balance and coordination
To reduce pain in specific areas
To reduce physical tension in specific areas
If you are experiencing pain and/or physical tension in specific areas of your body, please describe. Also indicate if you have seen other health professionals for this condition, and if you have a diagnosis.
For Massage Therapy: What are your preferences with regard to depth of pressure?
I prefer light to moderate pressure
I prefer moderate pressure, but deeper pressure is okay when necessary (within my pain tolerance)
I usually prefer deep pressure, and have a high pain tolerance
Is there anything else that you would like me to know about your reasons for seeking private yoga/massage at this time?
5. MEDICAL HISTORY
Are you currently under medical supervision? If so, please explain.
Are you currently taking any medications? If so, please list:
Please review all of the following conditions and check any that apply:
Shortness of Breath
Head & Neck
Vision Problems or Loss
Congestive Heart Failure
Low Blood Pressure
High Blood Pressure
Loss of Sensation
Loss of Sensation
Other Diagnosed Conditions
*Disclosure of HIV status is optional, but please note that it will not result in denial of treatment
Please feel free to elaborate on any of the conditions that you checked above, or add any additional information that you feel may be helpful.
6. INFORMED CONSENT AND RELEASE (please check the box next to each of the following statements:
I acknowledge that I have been given my physician’s permission to participate in private yoga sessions and/or receive massage therapy (whichever applies) with Jason Ray Brown, or that I am choosing to participate without the approval of a physician.
I agree to exercise reasonable caution for my own well-being, understand that my participation is at my own risk, and do hereby assume all responsibility for my participation in said activities. I understand that if I experience any discomfort during the private yoga and/or massage therapy sessions I will inform Jason so that he can adjust the intensity and/or depth of pressure to my level of comfort.
I understand that Jason is not a physician, and therefore is not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said during the massage and/or yoga sessions should be construed as a diagnosis or prescription.
I release and hold harmless Jason Ray Brown from any and all liability arising from injury or other loss to me or my personal property that may arise from my participation in any of the yoga and/or massage sessions in which I have voluntarily enrolled.
SCHEDULE AN APPOINTMENT
HOW TO CONTACT ME:
Check out Zenyasa Yoga & Bodywork on Yelp
TERMS & CONDITIONS