Watsu® & Therapeutic Pool Client Intake Questionnaire & Consent Form Name * First Name Last Name Email * Address * Date of Birth Emergency Contact Name and Number * Who were you referred by? What inspired you to receive this session? What is your main intention for this session, if different from above? Have you every had Watsu® before? Yes No Do you have health concerns that you may have or are currently being treated for? Yes No Do you currently see any other practitioner for this/these concerns? Yes No Please list any current medications. What is your level of comfort in the water? 1 - uncomfortable, 10 - very comfortable 1 2 3 4 5 6 7 8 9 10 What is your susceptibility to motion sickness? 1 - unsusceptible, 10 - very susceptible 1 2 3 4 5 6 7 8 9 10 Do you do any type of regular exercise? Yes No If yes, please describe Do you have certain movements or activities that are limited? Yes No If yes, please describe. Are there any movements or positions that increase this limitation? Yes No If yes, please describe. Are there any movements or positions that decrease this limitation? Yes No If yes, please describe. Is there any part of your body that is sensitive to touch, massage, or stretching? What is your pressure preference? Light Medium Firm What is the current pain/discomfort level you experience regularly? 1 - bearable, 10 - unbearable 1 2 3 4 5 6 7 8 9 10 Do you have any of the following: open wounds/rashes/skin conditions, diabetes,seizures, any heart/circulator condition, any respiratory/lung condition, high orlow blood pressure, loss of sensation/numbness, any infectious disease, chlorinesensitivity, heat sensitivity, dizziness or motion sickness, traumatic braininjury/concussion, traumatic vehicle accident, PTSD? Yes No If yes, please describe. Is there anything else you would like to share about yourself, your condition, your specific problems or needs? Feel free to wiggle or adjust your head and neck so you are always in the bestposition possible. Tell your practitioner if you need more or less pressure with anymassage or stretch. There will be periods of stillness and movement. If you wishfor more stillness at anytime, tell your practitioner. If you are uncomfortable at anytime, tell your practitioner so that yourposition can be adjusted. If you wish to stop the session for any reason, please tell your practitioner. * I understand that Watsu®/Aquatic Bodywork is provided for stress reduction,relaxation, relief from muscular tension, improvement of circulation andpromote energy flow. I understand that I am receiving this session from a practitioner in training. If I experience pain or discomfort during the session, I will immediately informmy practitioner so that the session can be adjusted to my level of comfort. Iwill not hold my practitioner responsible for any pain or discomfort Iexperience during or after the session. I affirm that I have notified my practitioner of all known medical conditionsand injuries. I agree to inform the practitioner of any changes in my health and medicalcondition. I understand that there shall be no liability on the practitioner’s partshould I forget to do so. I understand that Watsu®/Aquatic Bodywork is entirely therapeutic and non-sexual in nature. By signing this release, I hereby waive and release my practitioner from allliability, past, present, and future relating to sessions in the Watsu®/AquaticBodywork. Please Type Your Full Name Below * By Typing your name you are signing this form. Date * MM DD YYYY Thank you!
