Bodywork Intake Form

Kristina Amelong, CCT, CNC

Bodywork Intake Form

Secure Client Intake Form:
Massage or
Enema Series

IMPORTANT! Please ensure that you have a stable internet connection when completing this online form, especially if you will invest time in providing detailed responses. (A partially completed form cannot be saved.)

The Optimal Health Network respects the privacy of its clients. All personal information provided on this secure form will be held in strict confidence and will not be released to any third party without prior written authorization.

* Date: (required)

* First Name: (required)

* Last Name: (required)

* Date of Birth: (required)

* Phone: (required)

* Your E-mail: (required)

* Confirm E-mail: (required)

* Street:
* City: * State: * ZIP:
(mailing address required)

* Is this your first in-person appointment or consultation with Kristina? Enter YES or NO. (required)

Emergency Contact Name:

Emergency Contact Phone:

If you are not already subscribed to OHN's e-newsletter, may I sign you up?
Enter YES or NO.

HEALTH HISTORY

Are you currently under the care of a physician or healthcare provider? Enter YES or NO.

If YES, please specify:

Do you have any of the following conditions? (check all that apply)

high blood pressurelow blood pressureheart diseasediabetesvaricose veinsblood clotscancerosteoporosisarthritisfibromyalgiasciaticamigrainesskin conditionsrecent injuries (describe below)surgery (last 6 months)pregnancy (include due date below)digestive disordersother (describe below)

Comments on conditions:

Do you have any allergies (oils, lotions, scents, latex, etc.)? Enter YES or NO.

If YES, please specify:

Do you experience chronic pain or tension? Enter YES or NO.

If YES, please specify where:

What areas would you like to focus on during your session?

Have you ever received professional massage or an enema series before?

Yes, massage.Yes, enema series.

Do you have any sensitivities to touch, pressure, or abdominal work? Enter YES or NO.

If YES, please specify:

Are there any specific goals or concerns you would like to address?

MASSAGE PREFERENCES (if applicable)

(For clients receiving this service, please answer the following questions.)

Preferred pressure:

lightmediumfirmdeep

Areas to avoid (if any):

Are you comfortable with the use of aromatherapy or essential oils? Enter YES or NO.

PROSTATE MASSAGE (if applicable)

(For clients receiving this service, please answer the following questions.)

Have you ever received a prostate massage before? Enter YES or NO.

Are you currently experiencing any prostate-related issues or discomfort? Enter YES or NO.

If YES, please specify:

Do you have any concerns or questions about our prostate massage service?

ENEMA SERIES (if applicable)

(For clients receiving this service, please answer the following questions.)

Have you ever received an enema or enema series before? Enter YES or NO.

What is your primary reason for seeking an enema series? (check all that apply)

detoxificationchronic constipationbloatingdigestive healthcolon cleansingliver supportparasite cleanseother (describe below)

Comments:

How often do you have bowel movements?

dailyevery other daya few times per weekonce a week or less

Do you have any of the following digestive issues? (check all that apply)

irritable bowel syndrome (IBS)leaky gut syndromehemorrhoidsacid refluxfood sensitivitiesfrequent gas/bloatingother (describe below)

Comments:

Are you currently taking any medications or supplements that affect digestion? Enter YES or NO.

If YES, please list:

Do you have any concerns or questions about our enema series service?

SUPPORTING DOCUMENTS (if applicable)

Using the buttons below, please attach any relevant supporting documents below.

PERMITTED FILE TYPES: pdf, doc, docx, txt, xls, xlsx, odt, ppt, pptx, jpg, jpeg, png, gif

PLEASE NOTE: Maximum file size permitted is 3MB per attachment. If you are unsure whether an attachment exceeds 3MB, please do not attach, as it may prevent the form from being submitted successfully. You can also email any supporting documents to me at kristina@ optimalhealthnetwork.com.

PLEASE READ before submitting!

Upon submitting this form, a link for booking an appointment will appear on this screen. If you are a first-time in-person client, please follow this link to schedule an initial 15-minute Zoom meeting with Kristina at no charge (or a standard phone call if a Zoom meeting is not possible for you). This appointment is to determine if we are a good fit to work together and establish expectations. During this initial Zoom (preferred) or phone meeting, your massage and/or enema series appointment will be scheduled.

If you are a returning in-person client, there is no need to schedule another intake meeting. Please call us at (608) 242-0200 to schedule your massage or enema series.

Submission of this form may take up to 30 seconds after the Submit button is clicked. Thanks for your patience. Please do not refresh the page or use the back button!