Please read and initial.
__I have informed Jane Ella of any movement restrictions prescribed by my doctor.
__If such conditions exist, I have medical clearance for normal activity.
__I have informed Jane Ella of any movement restrictions prescribed by my doctor.
__If such conditions exist, I have medical clearance for normal activity.
®
CLIENT INFORMATION FORM
Name (L)___________________________ (F)___________________ D.O.B.___/___/___
Address:_____________________________________________________Name (L)___________________________ (F)___________________ D.O.B.___/___/___
_____________________________________________________
Phone _______ _______ ____________ E-mail _______________________________
Emergency Contact / Rel:___________________________ Phone # _______________
Occupation / pastimes: ____________________________________________________
What are your concerns / goals? ____________________________________________
________________________________________________________________________
Referred by _____________________________________________________________
PLEASE READ AND RESPOND:
__ I have been given a description of the Feldenkrais
Method.
__I understand that the Feldenkrais Method is not a medical or chiropractic treatment.
It does not diagnose or cure medical conditions or subluxations, nor is it intended
as a substitute for the care of a physician.
__I understand that the Feldenkrais Method is primarily an educational approach. It
does not involve massage techniques and is not a form of Therapeutic Massage.
__I give Jane Ella permission to leave telephone messages regarding the
scheduling of sessions.
CLIENT SIGNATURE: _________________________________ DATE ______________
__ I have been given a description of the Feldenkrais
Method.
__I understand that the Feldenkrais Method is not a medical or chiropractic treatment.
It does not diagnose or cure medical conditions or subluxations, nor is it intended
as a substitute for the care of a physician.
__I understand that the Feldenkrais Method is primarily an educational approach. It
does not involve massage techniques and is not a form of Therapeutic Massage.
__I give Jane Ella permission to leave telephone messages regarding the
scheduling of sessions.
CLIENT SIGNATURE: _________________________________ DATE ______________
__Heart __Stroke (Date______________)
(__High __Low) Blood Pressure
__Cancer _________________________
__Blood Clots __Vericose Veins
__Diabetes
__Osteoporosis
__Joint Replaced ________ Date ______
__Injuries _________________________
__Allergies ________________________
__Contagious Disease ______________
(__High __Low) Blood Pressure
__Cancer _________________________
__Blood Clots __Vericose Veins
__Diabetes
__Osteoporosis
__Joint Replaced ________ Date ______
__Injuries _________________________
__Allergies ________________________
__Contagious Disease ______________
__Nervous System (brain, nerves, spine) _____________________________________
__Other Conditions _______________________________________________________
________________________________________________________________________
__Other Conditions _______________________________________________________
________________________________________________________________________
Medical History: Please check and explain any problem areas that apply to you.
Jane Ella Matthews, M.Ed,
Feldenkrais® Practitioner
jemtt1@icloud.com
(864)918-9281
Feldenkrais® Practitioner
jemtt1@icloud.com
(864)918-9281
