KZP Wellness Retreat Intake Form 2016

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NAME:____________________________________ DATE:_____________________

E-MAIL:____________________________________ BIRTHDAY:_______________

ADDRESS:

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CITY, STATE, ZIP:

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TELEPHONE: H: ________________ W:_______________________

M:____________________

EMERGENCY CONTACT:__________________________________

INJURIES/MEDICAL CONDITIONS?

______________________________________________________________________________

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DO YOU CURRENTLY PRACTICE PILATES OR YOGA?

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FOR HOW LONG HAVE YOU PRACTICED PILATES AND/OR YOGA?

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WOULD YOU DESCRIBE YOURSELF AS

AN ADVANCED PILATES PRACTITIONER

AN INTERMEDIATE PILATES PRACTITIONER

A BEGINNING PILATES PRACTITIONER

AN ADVANCED YOGA PRACTITIONER

AN INTERMEDIATE YOGA PRACTITIONER

A BEGINNING YOGA PRACTITIONER

WHAT DO YOU HOPE TO GET OUT OF THIS RETREAT?

______________________________________________________________________________

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HOW DID YOU HEAR ABOUT KEVYN ZELLER WELLNESS RETREATS?

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MASSAGE PROFILE:

Please mark any of the following that you now have or have had:

Musculoskeletal

Bone/Joint Disease __

Tendonitis/Bursitis __

Arthritis/Gout __

Jaw Pain (TMJ) __

Lupus__

Spinal Problems __

Other______________________________________________________________________

Skin

Allergies, specify ____________________________________________________________

Rash__

Athletes Foot __

Herpes/Cold Sores __

Eczema/Psoriasis __

Migraines/Headaches __

Other________________________________________________________________________

Additional Client Remarks Comments:__________________________________________

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Have you ever experienced professional massage or bodywork? __Yes __No How

recently? What are your massage or bodywork goals? ____________________________

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What kind of pressure do you prefer? __Light __Medium __Firm

Is there a specific part of your body that you would like for the therapist to work on?

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FOOD ALLERGIES/AVERSIONS

Please describe any food allergies and aversions you have: _______________________

______________________________________________________________________________

______________________________________________________________________________

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Client Signature_______________________ Date: ______________________

We have made each of our forms easy to download. Please feel free to download your forms here:

INTAKE FORM

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RETREAT WAIVER

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RETREAT POLICIES

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