Blackbird Wellness VT | Health History Form

Thank you for scheduling an appointment! If you are a new client with Jennifer Marriott and Blackbird Wellness VT, we please ask that you fill out this form prior to your first treatment.

Name

First Name

Last Name

Preferred Pronouns

Email Address

Mailing Address

Phone

Emergency Contact

Name and phone

Date of Birth

MM-DD-YYYY

Primary Physician

Name and phone

Medications or allergies

If yes, please list below:

Have you ever received professional bodywork before? If yes, what and when was your last treatment?

What results do you expect from treatment?

Is there a specific ailment that you would like the therapist to address?

What are your current exercise habits?

Sleep Habits

Please select one that best describes your current state:

Poor (very little sleep wake regularly 1-4hrs)

Average (moderate sleep wake sometimes 5-7hrs)

Great (sleep soundly and undisturbed 8+hrs)

Please describe any medical conditions you have:

Bodywork and certain exercise movement can be contraindicated for some medical conditions, please always consult with your primary care physician prior to treatments if you are unsure.

Please share briefly how you heard about us:

Is there someone we should thank for the referral?

Signature

By signing below you are confirming the information you recorded is best to your knowledge, and that you have consulted with your physician to be cleared if you have any medical conditions or issues that may be contraindicated for massage.

Date

YYYY