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Intake Form
If you would like to schedule an appointment at Tera's NYC office, please call 212.371.0700 or 212.249.7711. If you would like to schedule and appointment at Tera's Santa Fe office, please call 917.597.9698. After scheduling your appointment please fill out the intake form below.
Name
Gender
Address
Address (con't)
City
State
Zip Code

Email
Telephone
(Day)
Telephone
(Evening)
Marital Status
Number of Children
Occupation
Referred By

FINANCIAL POLICY
PAYMENT (CHECK OR CASH) IS REQUESTED AT THE END OF EACH VISIT, UNLESS SPECIFIC ARRANGEMENTS ARE MADE.

CANCELLATION POLICY
THE TIME OF YOUR APPOINTMENT IS RESERVED FOR YOU. APPOINTMENTS CANCELLED WITH LESS THAN 48 HOURS NOTICE WILL BE CHARGED FOR PAYMENT IN FULL.
Signature
Date

WHAT ARE YOUR GOALS FOR RECEIVING THIS WORK?

PERSONAL HEALTH HISTORY
HEIGHT
WEIGHT
DO YOU HAVE ANY AREA OF YOUR BODY THAT NEEDS SPECIAL CONSIDERATION?
IF YES, PLEASE EXPLAIN
DATE OF LAST MEDICAL EXAM
ARE YOU CURRENTLY UNDER MEDICAL CARE?
IF YES, PLEASE GIVE THE NAME OF PROVIDER AND CONDITION BEING TREATED
ARE YOU PRESENTLY TAKING ANY MEDICATION?
IF YES, PLEASE LIST NAMES OF MEDICATION(S), FOR WHAT CONDITION
ARE YOU PRESENTLY USING ALCOHOL OR NICOTINE?
HAVE YOU EVER WORN BRACES?
HOW WOULD YOU DESCRIBE YOUR DIET?
DO YOU TAKE VITAMINS, HERBS OR OTHER DIETARY SUPPLEMENTS?
IF YES, PLEASE DESCRIBE
HAVE YOU EVER RECEIVED BODYTHERAPY?
IF YES, PLEASE DESCRIBE AND FOR WHAT PERIOD OF TIME
ARE YOU CURRENTLY RECEIVING REGULAR BODYWORK OR OTHER THERAPY?

HEALTH HISTORY
HAVE YOU EVER HAD ANY TYPE OF ACCIDENT?
IF YES, PLEASE DESCRIBE AND INCLUDE DATES
HAVE YOU EVER BROKEN ANY BONES OR HAD SEVERE FALLS?
HAVE YOU EVER HAD ANY TYPE OF SURGERY?
IF YES, PLEASE GIVE TYPE(S) AND DATE(S)
DO YOU HAVE ANY LIMITS IN MOBILITY?
IF YES, PLEASE DESCRIBE
DO YOU EXERCISE?
PLEASE DESCRIBE TYPE AND FREQUENCY
DESCRIBE METHODS YOU USE TO MANAGE STRESS IN YOUR LIFE
WHAT DO YOU DO FOR FUN?
ANY ADDITIONAL COMMENTS REGARDING YOUR HEALTH – PLEASE DESCRIBE ANY OTHER CHRONIC OR ACUTE CONDITIONS, I.E. LOW/HIGH BLOOD PRESSURE, DIABETES, ULCER, SLEEP DISORDERS, ETC.
ANYTHING ELSE ABOUT YOUR LIFE HISTORY OR CURRENT SITUATION THAT I SHOULD KNOW AT THIS TIME?

BIRTH INFORMATION/HISTORY
AN UNDERSTANDING OF YOUR BIRTH IS A SIGNIFICANT PART OF THIS WORK. TRAUMA MAY HAVE OCCURRED DURING THE BIRTH PROCESS AND EARLY PATTERNING OR IMPRINTING MAY BE REVEALED DURING YOUR SESSIONS. (THIS WILL BE EXPLAINED IN MORE DETAIL).
PLEASE RELATE ANY INFORMATION YOU MAY HAVE REGARDING YOUR CONCEPTION: (PLANNED, WANTED, CONFUSED, UNWANTED)
PLEASE CHECK WHAT YOU KNOW OR THINK APPLIES TO YOUR BIRTH HISTORY
AN UNMEDICATED VAGINAL BIRTH IN A HOSPITAL
AN UNMEDICATED VAGINAL BIRTH AT HOME
AN ANESTHESIA BIRTH
WITH FORCEPS
VACUUM EXTRACTION
WITH FETAL HEART MONITOR
C-SECTION
BREECH
A MULTIPLE BIRTH
PRIOR MISCARRIAGES (BEFORE YOU WERE CONCEIVED)
OTHER BIRTH COMPLICATIONS
IF CHECKED OTHER BIRTH COMPLICATIONS, PLEASE DESCRIBE
PLEASE CHECK WHAT YOU KNOW OR THINK APPLIES TO YOUR PRENATAL AND BIRTH HISTORY
I HAD A TWIN THAT DID NOT LIVE
AT WHAT TIME IN THE PREGNANCY OR POST NATAL TIME DID THE TWIN LEAVE?
I WAS PREMATURE
HOW MANY WEEKS?
I WAS IN A NEONATAL INTENSIVE CARE UNIT
HOW LONG?
I WAS IN AN INCUBATOR
HOW LONG?
WAS YOUR FATHER PRESENT AT YOUR BIRTH?
WERE YOU SEPARATED FROM YOUR MOTHER AT BIRTH (SENT
TO A NURSERY)?
WERE YOU BREAST FED?
IF YES, FOR HOW LONG?
PLEASE NOTE ANY INTERVENTIONS SHORTLY AFTER BIRTH SUCH AS HOSPITALIZATION FOR ILLNESS, OPERATIONS, ILLNESS AS AN INFANT OR A CHILD.
WHAT DO YOU KNOW ABOUT YOUR LIFE IN THE WOMB? I.E PHYSICAL EFFECTS (MATERNAL OR PATERNAL SMOKING, DRINKING, DRUGS, MOM’S DIET) AND EMOTIONAL EFFECTS, INCLUDING ABSENCE/PRESENCE OF FATHER DURING PREGNANCY/BIRTH, PARENTS’ RELATIONSHIP, FAMILY TRAUMA?
DO YOU OR DID YOU HAVE SIBLINGS? INDICATE AGES RELATIVE TO YOU, NATURE OF RELATIONSHIP AS CHILDREN.
ADDITIONAL COMMENTS

PLEASE MAKE YOUR ANSWERS AS COMPLETE AS POSSIBLE. YOUR ANSWERS WILL HELP ME TO CUSTOMIZE YOUR SESSIONS TO YOUR GREATEST BENEFIT. THANK YOU.

PLEASE PRESS THE "SEND" BUTTON WHEN YOU ARE FINISHED FILLING OUT THE INTAKE FORM.

Dislcaimer: This treatment is not meant to take the place of allopathic medicine. If you have, or suspect you have, a health problem,or have questions about your individual medical situation, you should consult your physician or other qualified health-care provider.


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