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Home
About
Services
Contact
Intake Form
Name
Email
Cell Phone Number
DOB
Occupation
At a computer, desk? If so how many hours/day?
Are you currently under a physician's care?
Yes
No
If yes, any diagnosis?
List medications
List supplements
What type of physical activity do you do each day?
For how long, how many times a week?
Hobbies?
What makes you happy?
Areas of physical pain/tension
Is the pain chronic?
Yes
No
What makes it worse?
On a scale of 1-10 (10 is terrible) how do you rate each pain site?
1
2
3
4
5
6
7
8
9
10
How long has the pain been present?
Was it caused by an accident, injury, illness, surgery?
Do you know the cause of the pain?
Do you have pain without having had an injury?
What helps with the pain?
List surgeries
List accidents
List injuries
List scars with location
Are you experiencing an increased amount of emotional stress?
Would you describe your mental and emotional state as good?
Are there areas in your life (relationships, job, etc.) that you would like to see change or improvement in (can be mental, emotional, physical)?
Are you happy?
Is your internal voice negative, self deprecating, mean or anything that is not positive?
Are there situations in your life that continue to play out the same way, ie repetitive, negative outcomes that feel eerily similar?
Are there events and or people currently or from the past that feel triggering that you would like to get past to feel neutral about?
Do you have negative, repetitive thought patterns? (think "carbs are bad", "I'm not good at...")
Do you feel like you have a healthy relationship with food?
Is your body image positive?
Are you aware of lessons taught to you in childhood that you feel don't serve you now that you'd like to get past?
‘I certify that I have disclosed all information about any conditions that may be affected by massage, i.e. conditions listed above. ***MPS is contraindicated for individuals with epilepsy, a pacemaker and during pregnancy. I will advise Claudia Osman, LMT if the amount of pressure is too much or not enough. I agree to drink water throughout the day after the massage. I agree to give 24 hours notice of cancellation of the appointment. I agree if less notice is given that the therapist may charge for the appointment time. I acknowledge that a missed appointment prevents others from receiving treatment.
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443 B Carlisle Drive · Herndon, VA 20170
(703) 862 2927
