How did you hear about Wandering Bear Wellness?
What is your dream in Life?
At what stage are you in making that dream a reality? *
What are you goals for receiving work from Wandering Bear Wellness? *
1. Areas of discomfort/pain
2. Onset of discomfort/pain
3. Rate of Pain
Very little 1
5 Very Painful
4. Frequency on Pain
5. At what time of day is the pain at its worse?
6. Have you ever injured this area before? (explain)
7. Have you ever been in an accident (automobile, work, falls, etc.) ?
8. List all related treatments received for this injury
9. Is there anything you do that creates, increases or decreases pain?
10. What are the physical duties required of your occupation? *
11.Are you currently seeing any other healthcare professional?
Do any of the following apply to you?
Blood Clots (Legs or Lungs)
Warts, Rashes, Toe Fungus
Herniated/Bulging/ Ruptured Disks
Neck feels out of place
Pain at neck shoulder junction
Muscle spasm in neck
Pain when turning head
Gliding/Grating sound with neck movement
Pain with side to side movements
Diagnosed bone spurs
Pain or numbness
Pain or numbness in Shoulders
Pain or numbness arms or hands
Pain or numbness in your back
Pain or numbness hips
Pain or numbness legs
Please elaborate on any checked boxes.
Have you ever received Structural Integration or BodyWork? *
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How would you describe your experience?
Do you have any questions, concerns or anything you want to know more about?
Client information are confidential and written authorization is required to release any information. Do to the nature of the work and the need for the full time of the session any arrivals 15 minutes or more late may be subjected to cancelled session and charge for the full price. 24 hour cancellation notice is required, and you will be charge full price if missed. You will have a consultation with your therapist to discuss the session. I understand the purpose of Structural Integration is to align and lengthen the body on it's center line and in space. Alignment occurs through a series of physical contacts, body centered education, and movement training. Structural Integration is a type of body work focusing on the fascia. Fascia is the connective tissue that surrounds muscle. I understand Wandering Bear Wellness is not involved with the treatment of disease of any kind; nor does it substitute for medical diagnosis or treatment when such attention is deemed necessary by a licensed physician. Nothing said or done by Wandering Bear Wellness should be misconstrued as such. In addition, I understand that any relief of physical or emotional symptoms is coincidental in the centering of the physical body and not the direct aim of Structural Integration. Wandering Bear Wellness does not bear any responsibility for any medical or emotional condition occurring while receiving, but otherwise not related to Structural Integration. I understand it is necessary for my practitioner, to touch my body in an appropriate manner in order to assist me in my Structural Integration experience. I give Wandering Bear Wellness my permission and consent to physically assist my body in the Structural Integration session. I further understand that I may, at any time, revoke such permission and consent, and can choose to discontinue the session and any further Structural Integration appointments. I understand that revocation of my involvement in Structural Integration does not release me from the cancellation policy. I agree to inform my Practioner at any point if I feel discomfort or pain during the session. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health have status. By submitting this form, I agree to the policy and client agreement above. PLEASE USE THE KEYPAD TO SIGN BELOW.