Client Intake Form

Please fill out the following form with as much detail as possible, in order to provide you with the best possible treatment tailored to your specific needs

    Please select or type a date
    Please select or type a date
    General wellnessDepressionSleep deprivationAnxietyPain reliefRelaxation

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    NormalHighLow NOYES

    Have you had massage therapy before? Have you ever experienced PEMF therapy? Have you had cupping therapy before? Please mark YES or NO if you experience or have any of the following: Includes cardiac pacemakers, cochlear implants, insulin pumps, or neurostimulators. PEMF may interfere with their function. YESNO The effects of PEMF on fetal development have not been adequately studied. YESNO PEMF is generally contraindicated for active malignancies, as it may theoretically promote tumor growth (though this is debated and requires further study). YESNO Particularly for high-intensity PEMF, as it might provoke seizures. YESNO PEMF may enhance circulation, potentially worsening active bleeding. YESNO PEMF may exacerbate the inflammatory response during an active infection. YESNO PEMF can improve circulation, which might dislodge a clot and lead to embolism. YESNO

    (*Medical emergencies are exempt).
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    Please type your initials as a sign of acceptance

    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. I understand that PEMF therapy uses electromagnetic fields to promote healing and that: - Sessions may typically last 15-30 minutes. - Effects may vary from person to person. - Some people may experience temporary fatigue or mild discomfort. - Multiple sessions may be needed for optimal results. - Individuals with electrical implants (pacemakers, etc.). - Pregnant women. - Active bleeding or hemorrhage. - Active cancer treatment (unless approved by physician).
    for ElectronsPlus Therapy
    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.
    for Deep Myofascial Cupping

    NOYES