Date of Birth:

MM

DD

YYYY

Do you require a home visit? *

Travel costs are applicable

Yes

No

Contact preference to book the first session *

Email

Telephone

Do you have or have you ever had: *

Allergies

Arthritis

Back Problems

Blood Clots

Cancer

Chronic Pain

Contagious / Infectious condition

Corns on the feet

Diabetes

Epilepsy

Headaches

Heart Conditions

High/Low Blood Pressure

Joint replacement

Knee Problems

Non-Specific Pain

Orthodontic treatment

Orthopedic treatment

Osteoporosis

Pregnant or Post-Partum

Recent fractures or sprains

Recent surgery

Root canal treatment

Seizures

Skin Disorders

Spinal Conditions

Stroke

Swelling / Oedema

Thrombosis / Embolism

Verrucas

Warts on the feet

None of the above

Are you currently taking any medication? *

Yes

No

How do you rate your pain today?

Please refer to the Universal Pain Assessment Tool

1

2

3

4

5

6

7

8

9

10

Are you predominantly a mouth breather?

Yes

No

I don't know

I am prone to over-training when I exercise:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

Do you walk your dog on the same side most days?

Yes - Left Side

Yes - Right side

No

Not relevant

Do you carry a bag mainly on one shoulder?

Yes - Left Side

Yes - Right side

No

Not Relevant

Do you sleep on the same side of the bed most nights?

Yes - Left Side

Yes - Right side

No

Day-to-day I have a lot of energy:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

Day-to-day I feel stressed:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

My work shoes are uncomfortable:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

My job is stressful:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Not Applicable

I have a sedentary lifestyle:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

How did you hear of Movementum?

AiM Online Practitioner List

Personal Recommendation

Web Search

Instagram

YouTube

Pinterest

Other

Medical/Liability Waiver *

I am fully aware that the services I wish to receive are those of a holistic nature and do not serve as a substitute for professional medical advice, examination, diagnosis or treatment. I understand the information I have been given to be the truth and consent to the treatment of Anatomy in Motion and will inform Frances of any changes to my medical status if they have changed since completing this online form. I understand that if I have been untruthful with my details or have failed to give enough relevant information any treatment could be adversely affected. Frances does not claim to cure or to diagnose any medical condition in the same regard as a physician, as her opinion is that of a holistic, complementary and alternative therapist and her professional opinions, advice, examinations and recommendations do not constitute the medical advice of a doctor/physician.

I understand and agree to the above

Session Booking *

If a date cannot be agreed at the end of an in-person session it is up to you, the client, to ensure you book all of your sessions. Movementum will not be held responsible for ensuring all packages and sessions are used and are unable to remind you to book appointments outside of session hours.

I understand and agree to the above

Late Arrival Policy *

We request that you arrive 10 minutes prior to your first session to allow time to fill out any required paperwork and 5 minutes prior to all other sessions. We understand that issues can arise that may cause you to be late for your sessions. However, we ask that you contact us if this ever occurs so we can do our best to accommodate you. As we run on a tight schedule, clients who arrive late to their appointment may receive a shorter treatment in the effort not to inconvenience other booked clients.

I understand and agree to the above

Cancellation Policy and Missed Appointments *

We want to make our policy as clear as possible as it can be upsetting when people miss or need to change an appointment, often because of genuine and stressful reasons. It is our policy that clients are responsible for all appointments that they have scheduled. Clients who choose not to attend, or those who call to cancel their appointments at the last minute are still responsible for these appointment times. Therefore the following policy will apply: We require a minimum of 24 hours’ notice for cancellation of a session via email, phone call or text message. For missed appointments, or any appointment changed, altered, moved or cancelled for any reason with less than 24 hours’ notice you will incur the full appointment fee. Short notice cancellations (less than 24 hours) will be counted as one of your sessions. I understand that emergencies can arise and illnesses do occur at inopportune times. If you have a fever, a known infection, or have experienced vomiting or diarrhoea within 24 hours prior to your appointment time, I request that you cancel your session. I will do my best to give advanced notice if I need to cancel due to bad weather and ask you do the same. Please do not risk your own safety trying to make your appointment.

I understand and agree to the above

Privacy Policy *

We do not share any of your information with any third parties or profit from your personal information and data. Our privacy policy can be found at the bottom of each page.

I understand and agree to the above

Declaration of consent: *

I have completed this form to the best of my ability and knowledge and agree to inform Frances if any of the above information changes at any time.

I understand and agree to the above

Date Today: *

MM

DD

YYYY