Name
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First Name
Last Name
Today's Date
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MM
DD
YYYY
Date of Birth
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MM
DD
YYYY
Email Address
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Preferred Phone #
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(###)
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Mailing Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
How did you hear about Triangle Body Therapy?
If referral, is there someone Owen can thank?
Primary concern or problem motivating you to seek treatment:
This problem causes difficulty with:
Approximately when did this problem begin?
If your primary problem is painful, please rate your pain on a scale of 1-10, with 10 being worst.
What other types of treatment have you tried to treat this issue?
Secondary problems or issues?
Cause difficulty with:
When did these problems begin?
If your secondary problems include pain, please rate your pain on a scale of 1-10, with 10 being worst.
What other types of treatment have you tried to treat these issues?
Please list the outcomes you want as a result of treatment:
task or activity / duration / how often / by when
Other therapeutic goal(s)?
Check any which currently pertain to you:
Other conditions you think Owen should know about
Please list your history of significant accidents, injuries and/or surgeries (including eye and/or dental surgeries) and approximate dates.
Please list any medications taken to control pain or to thin your blood
medication / for treatment of / dose / frequency / effectiveness
Other meds? (optional)
medication / for treatment of / dose / frequency / effectiveness
Do you eat a lot of plants fruits and vegetables everyday?
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How much water do you drink everyday?
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Do you exercise regularly?
If yes, what type, how often?
mild, moderate or strenuous?
Are you able to exercise now?
Do you get approximately 7-9 hours of sleep every night?
Do you wear:
Is there anything else you think Owen should know?
Consent for Treatment
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I give Owen Dodge permission to provide treatment that will include "hands-on" manual therapy and may also include instructions for my own therapeutic exercise. I understand that I am an active participant in my healing, and it is my responsibility to provide accurate and timely feedback to Owen regarding my response to treatment.
If I experience pain or discomfort during the session, I will immediately inform Owen so the techniques can be adjusted to my level of comfort. I may become aware of memories and/or emotions as a result of treatment, and I am free to express them as part of my healing process. I may experience pain and/or soreness after my treatment. I understand that this is part of my healing process. I can choose to stop the treatment completely for any reason, at any time, if I so choose.
I affirm that I have informed Owen of all my known medical conditions and will keep him updated as to changes in my medical condition. Owen does not diagnose any physical or psychological disorders, and nothing said or done by him should be misconstrued as such. Nor does Owen prescribe medications or perform high velocity, spinal manipulations. I am responsible for consulting a qualified physician for any physical and/or psychological ailments that I may have. I understand that Owen's work should not be a substitute for this care.
Cancellation Policy
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Your appointment time is reserved exclusively for you. Please provide at least 24 hours notice in the event that you need to reschedule or cancel your appointment. If you are sick or have had a fever in the past 24 hours, please reschedule. YOU WILL BE CHARGED 1/2 THE FEE for sessions missed for other reasons. This policy also pertains to emergency cancellations at Owen's discretion.
Digital Signature (Please type full name)
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