Intake Questionnaire - JulieJetzer.com

Date
MM slash DD slash YYYY
Client First Name*
Parent Name if client is a minor
Last Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Cell*
DOB*
MM slash DD slash YYYY
Referred by
Release and Terms Form
You must check to agree to all sections.
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I understand that I may go session by session, scheduled online or purchase discounted sessions as a package. The package may be pre-paid in office only with the sessions scheduled online using a special coupon code. There are no transfers, refunds or monetary value of sessions or coupon codes.
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I agree to give at least 24 hours' notice of rescheduling a appointment through the system. Cancellation of a session is to allow for future scheduling. There is no refund beyond three days of scheduling pre-purchased sessions. All pre-purchased sessions are valid for up to one year after purchase.
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I agree to forfeit pre-purchased session upon second cancellation or reschedule with less than a 24-hour notice.
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I understand that Corrective Core & Musculoskeletal Health, LLC provides neither medical nor psychotherapy or physical therapy services, and the session is not a substitute for medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have.
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I understand that Julie Jetzer LMBT, CPT is not a Physical Therapist and does not work with injuries. She would be happy to recommend one or more area Physical Therapists if that is the care I am looking for.
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I have stated all my known conditions along with surgeries and will take it upon myself to keep Corrective Core & Musculoskeletal Health LLC updated on my health changes.
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I understand that I should consult my physician or other healthcare practitioners before starting any exercise program about my current health, any medications I am taking, and supplements I plan to take during my program/s or session/s offered by Corrective Core & Musculoskeletal Health, LLC. Nothing stated or posted by Julie Jetzer, Corrective Core & Musculoskeletal Health, LLC, or Blossom Tree Wellness, LLC co-op partners and/or affiliates' services are intended to be, and must not be taken to be, the practice of medicine and/or medical advice, and/or care and they shall not be liable for any liability of any kind resulting from the use of any program/s or session/s in office or outside of set office appointments.
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I give my permission, for my therapist, Julie Jetzer, of Corrective Core & Musculoskeletal Health, LLC, to take notes, photos and videos, including health history/ medical and /or personal information I choose to disclose to her. I also give my permission, allow communication on my, my minor/infant's behalf with other health care providers.
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I accept full responsibility for participating in any Corrective Core & Musculoskeletal Health, LLC program/s or session/s and agree to communicate any and all physical discomforts or problems to my doctor/midwife and Julie Jetzer, owner of Corrective Core & Musculoskeletal Health, LLC. I accept all responsibility for my health and/or health of my infant or minor and any resultant injury or mishap that may affect me, my pregnancy, my baby/s, my minor/s, and/or well being while participating in such program/s or session/s. In the event, I and/or my minor or infant suffer any injury or discomfort while participating in or resulting, directly or indirectly, from my participation in this program/s session/s, I hereby waive any and all claims relating to such injury or discomfort against Julie Jetzer LMBT, CPT, Corrective Core & Musculskeletal Health, LLC and any of their respective agents or affiliates.
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I understand that results are not guaranteed.
Please select session type.*
- Corrective Core Method for Pregnancy
- Corrective Core Method
- Baby Balance Method for Pre-crawlers
- Breast Lymphatic Drainage with LET & MLD
- Body Lymphatic Drainage with LET & MLD
- Manual Lymphatic Drainage Pre & Post Surgery
Health History
Current Age?*
Please enter a number less than or equal to 99.
What are your three main goals or concerns for seeing Julie? (If this session is for an infant you may stop after you answer this question)*
Do you have any diagnosis of any kind?
- Yes
- No
If yes, what is your diagnosis?
Have you had a surgeries or have a surgery scheduled? Please give details.
- Yes
- No
What type of surgery? Oral, cosmetic, abdominal, joints, etc.
Do you have an IUD, Heart Passer, Diabetes Pump?
- Yes
- No
Are you presently or have you recently been under a doctor’s or PT care?
- Yes
- No
Have you had any surgical repairs of a hernia?
- Yes
- No
Was mesh used?
- Yes
- No
Have you had any laparoscopic surgeries?
- Yes
- No
Details of laparoscopic surgeries?
Is there any history of bladder (UTI) or kidney infections?
- Yes
- No
How often do you have a bowel movement?
What is your current stress level?
- 0 (low)
- 1
- 2
- 3
- 4
- 5 (high)

Release and Terms Form

Health History

Located within: TLC Wellness