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Client Information & Health History

All information, including contact information is confidential

Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Home Phone
Occupation
Referred By
Contact Lenses
- Yes
- No
Age*
Please list any medications you take and what for.
What is your major concern?
What are the symptoms?
When did you first notice the main complaint?
What activities aggravate the condition?
What time of day do you have the most pain?
Is this condition getting progressively worse?
- Yes
- No
- Constant
- Comes/Goes
What have you done to get relief?
Has there been a medical diagnosis? If yes what?
Diagnosing doctor?
Date diagnosed
Is there any similar family health history?
Food and Exercise Per Day:
Alcohol drinks
Sodas
Candy
Dessert
Sweet Snacks
Stretching
Strengthening
Do you currently have or have you had any of the following:
- High Blood Pressure
- Insomnia
- Spastic Paralysis
- Phlebitis
- Whiplash
- Arthritis
- Hematomas
- Cancer
- Fractures
- Chronic Constipation
- Herpes
- Skin Conditions
- AIDS
- Chronic Stiff Neck
- Heart Problems
- Chronic Head Aches
- Diverticulitis
- Varicose Veins
- Severe Lacerations
Have you been vaccinated?*
- Yes
- No
If yes, how many times?*
Have you had covid?*
- Yes
- No
If yes, how many times?*
Cancellation Policy: Appointments must be cancelled 48 hours prior to your scheduled appointment or you will be charged 50% of the rate for first offense. Full amount will then be charged for future offenses.

*** It is recommended that you get a medical doctor's opinion if you have a painful condition. The information provided by your massage therapist or bodyworker is for educational purposes and is not diagnostically prescriptive in nature.

++ I agree to participate as much as possible in my own healing.
Signature*
Date*
MM slash DD slash YYYY
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Skilled Neuromuscular and Craniosacral Therapy treatment can more easily and efficiently release the habituated patterns and provide relief.

Contact me for a free phone consultation and appointment

I feel grateful to have discovered a combination of techniques and personal skills that have allowed me to help clients where others haven’t been able to help.

CONTACT BRAD HIGHBERGER

541 South Main Street, Stowe, VT 05672

Phone: 802-730-4955

Email: info@vtpaintreatment.com

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APPOINTMENT HOURS

Tuesday-Saturday Call for availability. Closed Sun-Mon

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