Client Intake Form | truewellnessnj.com

Full Name

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Date of birth

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Emergency Contact Name

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Reason For Visit General wellnessDepressionSleep deprivationAnxietyPain reliefRelaxation Are you in pain right now? If YES, please explain: NOYES

Please explain:

Chronic conditions? If YES, please explain: NOYES

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Panic attacks? If YES, please explain: NOYES

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Lacerations or bad cuts? If YES, please explain: NOYES

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Can you please remember any/all injuries or accidents you've had in your life? (Old injuries can be negatively affecting you today) If YES, please explain: NOYES

Please explain:

Do you exercise? If YES, please explain how often and what is your regiment: NOYES

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Do you take medications? If YES, please list: NOYES

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How is your blood pressure NormalHighLow Please list all scars you may have either from injury or surgeries. (This is important because scars from any type of trauma can cause myofascial restrictions which in turn can cause muscle and/or joint pain). Do you have any history or issues with blood clotting? If YES, please explain in detail: NOYES

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24-Hour Cancellation Policy If I schedule an appointment in the future, I promise to pay for my session if I cancel without giving 24 hours of notice*. (*Medical emergencies are exempt).

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Please Read and Acknowledge the Possible Aftereffects of ElectronsPlus Treatments and Cupping Treatments ElectronsPlus Therapy ElectronsPlus treatments –aka PEMF therapy– is very powerful and will greatly improve blood circulation in the body. You may feel a deep sense of relaxation mixed with a burst of energy. Because of the therapeutic process you may experience detoxification symptoms like migraine headaches, muscle soreness, possible nausea and drowsiness. These symptoms are the body‘s way of pushing out toxins. This is a completely normal response. Please drink lots of water directly after your treatment. Electrolyte water is recommended.

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Deep Myofascial Cupping Please read this thoroughly before your first session This treatment is extremely powerful and highly effective. LONG TERM PAIN relief is usually noticed the most between session 5/7. Sooner in some cases. Toxins trapped in your body will be released into your blood stream causing headaches, lethargic feelings, drowsiness, possibly nausea. THIS IS THE NATURAL HEALING PROCESS. Drink plenty of water. Only use heat packs if needed on sore areas, AVOID ICE. These after effects become less noticeable after your first session. Cupping marks are almost always inevitable. They clear up usually in 5-14 days.

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Parental Consent for Minors (Disregard if you're an adult)

My name is

, and I am the parent/legal guardian of

I give permission to Michael Santana of True Wellness Therapies to perform therapeutic modalities for the benefit of my minor child. The therapies I approve include, but are not limited to: - Cupping Therapy - Massage Therapy - PEMF Therapy - Fascial Scraping Techniques

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