Progressions in Healing, LLC

Polarity , Craniosacral , Sound Healing , Massage & Reiki

Client Intake Form

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Medical Information:

Please check the box to all that apply and explain in the spaces provided. Do you have, suffer from or experience any of the following?


Frequent headaches:
Joint stiffness
Broken Bones in the past two years
Bone or Joint Disease, e.g., Arthritis, Scoliosis, Osteoporosis, Bursitis, Tendonitis
TMJ/Jaw Pain
Tension/Soreness in a Specific Area
Back pain
Numbness/Stabbing pains


Rashes, Skin Allergies, Acne
Recent Wounds, Cuts, or Severe Bruising
Are you very sensitive to touch/pressure in any area?

Nervous System:

Numbness/ Tingling?
Chronic Fatigue Syndrome/Fibromyalgia
Cerebral Palsy, Multiple Sclerosis, Muscular Dystrophy, Epilepsy, Parkinson's Disease.


Cardiac/CirculatoryProblems - Fainting/Dizziness
BloodPressure Problems?
Seizure Disorders/Epilepsy
Asthma, Allergies, Sinus, Shortness of Breath
Lymphedema, Swollen Ankles, Varicose Veins, Blood Clots, Stroke
Are you Diabetic?
Are you on medication for diabetes?


Are you wearing Contact Lenses?
Are you pregnant? If so, how many months?
Do you suffer frequently from Stress?
Have you had any Type of Surgery?
Do you have any other medical conditions that have not been mentioned above and that we should be aware of?

Polarity , Craniosacral , Sound Healing & Reiki


Rate your overall energy level at various times of the day: (0 - low, 10 - high)

Sleeping Patterns

Rate how well you sleep on average: (0 - not well, 10 - very well)
How would you rate your stress level in the past month: (0 - low stress level, 10 - high stress level).
How would you rate your emotional state in the past month? (0 - unbalanced, 10 - very balanced).

Please read the following information carefully and sign where indicated

I understand the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so the pressure and/or strokes may be adjusted to my level of comfort. I understand the goal is no discomfort and that communication is the key. If Polarity therapy is chosen, I have been made aware that it is a holistic, energy-based system, that will include bodywork, nutritional guidance, exercise, and lifestyle counseling for the purpose of restoring and maintaining proper energy flow throughout the body. The effectiveness of the treatment is dependent upon lifestyle changes; therefore, several sessions may be required before substantial benefits are evident. I further understand that massage/bodywork, Polarity therapy, and any other energetic structural therapy, such as Craniosacral therapy, should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should consult a physician, or other qualified medical specialist for any mental, emotional, or physical ailment of which I am aware of. I agree to keep all therapists at Progressions in Healing, LLC updated as to any changes in my medical profile and understand that there shall be no liability on the part of the therapist should I neglect to do so. In the event a medical emergency should occur while I am under the therapist care, I hereby authorize the staff at Progressions in Healing, LLC to call 911, in order to expedite treatment with professional medical personnel.

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