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Bloom Mobility
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Client Intake Form
Please complete this form prior to your first appointment
Full Name
Phone Number
Email
Birthday
Month
Day
Year
Emergency contact + their phone number
What brings you to integrated stretching?
Health and Medical History
Neck/trap pain
Back pain
Shoulder pain
Hip pain
Knee pain
Sciatica
Arthritis
High blood pressure
Vertigo
Pregnancy
Recent surgery
Joint replacement
Chronic pain
None
If any apply, please explain
Any current injuries?
Yes
No
If yes, please explain
How frequently do you exercise?
Daily
3-5x a week
1-2x a week
Rarely
What do you do for work?
Goals for working with Bloom Mobility
HYPER ICE SCREENING - do you have any of the following?
Blood clot history
Varicose veins
Severe bruising
Sensitive skin
Nerve pain
Recent fracture or sprains
Acute inflammation
None
Any additional concerns Bloom Mobility should know about?
By choosing yes you certify that all the information provided is accurate to the best of your knowledge and understand that it is your responsibility to notify Bloom Mobility of any changes to your health status.
Yes
No
Client Signature
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