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.
®
CLIENT INFORMATION FORM
Name (L)___________________________ (F)___________________ D.O.B.___/___/___
Address:_____________________________________________________
                 _____________________________________________________
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 ______________
 


__Heart __Stroke (Date______________)
(__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 _______________________________________________________
________________________________________________________________________

Medical History: Please check and explain any problem areas that apply to you.
 Jane Ella Matthews, M.Ed,
  FeldenkraisĀ® Practitioner
 
jemtt1@icloud.com
  (864)918-9281