New Client Portal

Welcome
Resources
The Sessions
- About Restorative Bodywork at EWTA
- Manageable Conditions at EWTA
The Seasons
More

Welcome
Resources
The Sessions
- About Restorative Bodywork at EWTA
- Manageable Conditions at EWTA
The Seasons
More

welcome!
After you book your first session...

this is an optional, general info intake form that will not replace the more thorough, initial in-person intake process. but, any info you can share here will help me prepare for our first visit.
This information cannot be encrypted when you submit it via email. please only answer what you are comfortable answering here. All else can be covered in person during our first meeting.
Thanks so much!

* Indicates required field

I understand that this questionnaire is a general information gathering intake, and does not replace the initial intake at EWTA. I understand it will be submitted through an unencrypted portal. I will only share personal information that I am comfortable sharing in an unencrypted format. *

I understand and agree

Name *

First

Last

Phone Number *

Email *

Were you referred to EWTA? *

Friend/ Family Healthcare Provider Social Networking Other Answer

History of Chiropractic care? *

Current and regular Current and infrequent In the past and regular In the past and infrequent Little to no experience Other

History of Osteopathic care? *

Current and regular Current and infrequent In the past and regular In the past and infrequent Little to no experience Other

History of Acupuncture? *

Current and frequent Current and infrequent In the past and frequent In the past and infrequent Little to no experience Other

History of Physical or Occupational Therapy? *

Current and frequent Current and infrequent In the past and frequent in the past and infrequent LIttle to no experience Other

History of Bodywork? *

Current and frequent Current and infrequent In the past and frequent In the past and infreqent Little to no experience Other

Other wellness niches or practices you'd like to share? *

What best describe/s your current need for bodywork? (Choose all that apply) *

Chronic pain mitigation New Injury Old injury Stress management Part of a wellness plan No complaint Somatic Embodiment Shiatsu (aka acupressure) Energy work Competitive athletic lifestyle Other

What style/s of bodywork and treatments are you interested in? *

Trigger point therapy aka neuromuscular Myofascial release Shiatsu aka acupressure Injury or chronic pain care Stretching Cupping or gua sha Kinesio-taping Light pressure Deep release Cranio sacral Energy work Light to no oils

Choose as many as are relevant to you

Includes cluster headaches, migraines, whiplash, text-neck, neck pain, facial pain, TMJ-D, etc. *

Head/ headaches/ neck

Any array of neck, shoulder and elbow complaints *

Right neck/ shoulder/ arm Left neck/ shoulder/ arm

Includes digestive discomfort, tight breathing, muscular pain, rib area pain, emotional holding patterns, etc. *

Right torso/ thoracic/ pectoral region Left torso/ thoracic/ pectoral region Abdominal region

Includes any array of hip injuries/ stiffness, weakness/ tightness, etc. *

Right anterior hip Left anterior hip

Includes tears/ weakness/ pain/ stiffness/ fasciitis, etc. *

Right knee/ quads/ shin Left knee/ quads/ shin Right foot Left foot

Includes cluster headaches, migraines, whiplash, text-neck, upper shoulder pain, etc. *

Neck Right neck-shoulder Left neck-shoulder

Includes upper back/ thoracic/ scapular/ shoulder girdle *

Right shoulder/ upper back left shoulder/ upper back Right middle/ thoracic back Left middle/ thoracic back

Any array of the entire lumbar- hip/ gluteal region complaints *

Right lumbar/ low back Left lumbar/ low back Right gluteal/ hip Left gluteal/ hip

From the back of the legs to the feet *

Right upper leg Left upper leg Right posterior knee Left posterior knee Right calf or foot Left calf or foot

Are there details about your quest for care you would like to share here? *

Thank you for taking the time to answer some or all of these first-step questions.
I'll look forward to meeting with you soon!

Submit

BOOK

607.279.9314
EWTAinfo@gmail.com

2023 East West Therapeutic Arts

Welcome
Resources
The Sessions
- About Restorative Bodywork at EWTA
- Manageable Conditions at EWTA
The Seasons
More

welcome!After you book your first session...

welcome!
After you book your first session...