Personal Information

Name

First Name

Last Name

DOB

YYYY

Current Age

Gender

Pronouns

Occupation

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact (Name, Relationship, Phone)

How did you find me?

Confidentiality & Release Form

I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health and understand that there shall be no liability on the practitioner's part should I fail to do so.

Please Initial

Please note: It is important that you complete this intake form in full. Arvigo® Therapy is a very powerful modality and certain medical conditions are contraindicated and determine if or when you can receive a session. After the consultation and review of the information you have provided on this form, it will be determined if Arvigo® Therapy should be administered to you. Some conditions will require a note from your doctor before proceeding. Please understand this is for your safety and well-being.

Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release form from their client before taking any information about them. The best way to be fully compliant is to obtain this release signature at the initial consultation. Clients may receive a copy of the form they signed (upon request), and the practitioner maintains a copy for their records. By signing below, I give my permission, for my practitioner to take notes including health history/medical and/or personal information I choose to disclose to him/her. I understand this information may be used for the purpose of practitioner certification and/or may be shared with the Arvigo Institute, LLC for statistical data collection only. All relevant identifying information will not be disclosed, such as name, contact information, address, and date of birth.

Please sign your name below:

Health Background & Information

Are you currently under the care of any other healthcare providers? If yes, please list below:

Do you have any allergies? If yes, please explain:

Have you had any surgeries? If yes, please explain:

Include Past, Present, and any known Future surgeries.

Have you ever been hospitalized? If yes, please explain:

Have you had any accidents or significant physical trauma? If yes, please detail:

Have you had any falls and/or injuries to your sacrum/tailbone/head? If yes, please detail:

Are your biological parents and maternal/paternal grandparents living? If not, please list age/cause of death and any significant health issues:

What is your primary reason for seeking Arvigo care?

Please share what you hope to achieve through embarking on the journey of this work:

When did you first notice this and what brought it on?

Describe any stressors correlated to this:

Is there anything you can recall that contributed to this?

What activites provide relief and what makes them worse?

Have you received any bodywork before? If yes, what kinds have you experienced?

How would you describe your general health?

Digestion & Elimination

Typical Breakfast

Typical Lunch

Typical Dinner

Typical Snack(s)

Daily Water Intake

Caffeine Intake

Tobacco/Nicotine Intake

Alcohol Intake

Fast Food Intake

Recreational Drugs (including Marijuana) Intake

Environmental Chemicals Exposure

(at home or workplace, including plastics, pesticides, disinfectants, metals, etc.)

Mold Exposure

Please describe your current movement/exercise rhythm:

Have you experienced or are you currently experiencing a stressful relationship to food/nourishment? If so, please elaborate:

How would you describe your bowel movements?

Emotional & Spiritual

What hobbies/activities bring you pleasure and a sense of accomplishment?

Take a deep breath - Describe the most positive, uplifting emotion you experience:

Where in your body do you feel this and how often?

Take another deep inhale & exhale - Describe the most negative or hurtful emotion you experience:

Where in your body do you feel this and how often?

Do you have a spiritual practice (prayer or ritual)?

If so, do you mind sharing a little bit? Typically, your practitioner would like to invite our spirits into the session.

Female Reproductive Health

Are you currently on contraception? If yes, please explain:

Are you currently receiving fertility treatment? If yes, please detail:

If applicable, please describe your menstrual cycle, historically and currently:

Are you currently trying to conceieve?

Is there a possibility that you could be pregnant?

If applicable, what were the results of your most recent pap smear?

Do you have knowledge of your own birth and early infancy? If so, please share anything you feel is significant.

If applicable, please detail your reproductive history in terms of pregnancies, births, terminations, birth loss and/or breastfeeding:

If applicable, how was your experience of the above?

How is your current relationship to sexuality?

Have you experienced trauma, specifically sexual trauma? If comfortable to do so, please elaborate, but please know you are not required to disclose further information.

If applicable, please share your experience of menopause:

Please explain below:

For Male Anatomies

If you have recently had a Prostate Specific Antigen (PSA) test, what were the results?

If you've ever had a Sperm Count test done, what were the results?

Do you have a family history of prostate cancer?

If yes, please explain

Do you have a family history of cancer?

If yes, please explain

Please describe your current relationship to self:

COVID Protocol

Do you now, or have you recently had any respiratory or flu symptoms?

Yes

Have you had a fever in the last 24 hours?

Yes

Have you been in contact with anyone in the last 14 days who has had COVID-19 symptoms?

Yes

Would you prefer your practitioner to wear a mask during your appointment?

I have no preference, without is just fine.

Yes, please!

Disclaimers

I understand that, because bodywork involves maintained touch and close proximity over an extended period of time, there may be elevated risk of disease transmission, including COVID-19.

Please Initial.

The Zen Chameleon and Practitioner, Courtney, reserves the right to refuse, postpone, or terminate treatment whenever we deem it in the best interest of one or more parties.

Please initial.

Release of Records/Permission to Communicate Consent: I hear-by give The Zen Chameleon and Practitioner, Courtney, to communicate with any and all practitioners involved in my treatment as they deem necessary. Please note: We will inform you of this line of communication if/when it needs to take place.

Please Initial.

Cancellation Policy: I agree to pay the full fee of service upon the day of service. I understand if I miss my service and do not give 24 hours notice of cancellation, that I am still held responsible to pay the full service fee.

Please Initial.

Minors: Parents must accompany any minor under 18 years of age to each and every appointment.

Please Initial.

By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner. I acknowledge that this facility and the therapist will not be held liable for indications that arise during or after the treatment, and I agree to notify the therapist if there is any discomfort during my session.

Please type your full name.

Arvigo® Therapy Intake Form