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In-Take Form

Stretch Abilitation > In-Take Form

client intake form

    Name:

    1. are you experiencing any of the following? (Check All That Apply)



    2. medical history update:

    Since your last appointment, have there been any changes to your medical history?

    [radio* yesradio-945 use_label_element “Yes” “No”]

    3. additional information for your therapist:

    Allergies to any lotion/oils?

    [radio* allergies-978 use_label_element “Yes” “No”]

    Wear Contact Lenses?

    [radio* lenses-526 use_label_element “Yes” “No”]