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Welcome to Sportbodywork Maui!

  • This is a required document and you will not be able to be seen by a therapist without this document completed.
  • If you are an established client of ours you do not have to fill this out each time. Only if your medical conditions have changed or it's been over 6 months since we've seen you.
  • If you are a newclient establishing care, please fill this out completely. This is not only medically required, but it helps us understand how best we can help you.
  • If it is for a minor, an adult must sign under guardian and guardian must be present for treatment.
  • Don't forget your beach towel for the table.

Please call the office if you need help (808) 868-1102

OFFICE LOCATION: Sportbodywork 2662 Wai Wai Place #104 Kihei HI 96753 


Cancellation /Late Policy:

I understand that Sportbodywork needs 48 hours or more notice to cancel or reschedule my appointment so that they can rebook it for another client. I can cancel and reschedule online using my login and profile or by calling the office (808)868-1102

I Agree

I understand f I cancel less than 24 hours from my appointment time, and the Sportbodywork Team cannot re-book the appointment time slot, I will be charged a 50% loss time fee.

I Agree

I understand that If I am within 8 hours of my appointment time, and I cancel or do not show up, my credit card will be charged for the time.

I Agree

If I am more than 5 minutes late for a scheduled session, that session will end on time so that the client following me is not penalized.

I Agree

Medical Disclaimer: 

It is my responsibility to inform my therapist if I am experiencing any pain so they can adjust to my level of comfort. We are not doctors and a therapy treatment and dialogue at our office should not be construed as a substitute for medical examination, diagnosis, or treatment. Licensed Massage Therapists are not qualified to diagnose, prescribe, or treat any mental or physical illness. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions (in person or on this intake form). I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist part should I fail to do so. 

I Agree

Therapist Rights:

I understand that the therapist has the right to determine and refuse a client who demonstrates inappropriate speech and/or behavior. Such speech/behavior will result in termination of the session. Payment for the terminated session shall be due and payable at the time of termination.

I Agree

I understand that the therapist has the right to refuse treatment of anyone lacking in basic physical hygiene, with any open wounds, or any symptoms of a communicable disease or virus.

I Agree

Covid 19

If I know that I have been exposed to an active Covid 19 case, I will reschedule my appointment for 5 days later to ensure I am not displaying symptoms and I am not testing positive.

I Agree

*If I display any cold or flu symptoms on the day of my treatment I will reschedule my appointment. (cancellation policy does not apply)




Please select who will be receiving treatment
AdultMinor
Continue
First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Information
How were you referred to Sportbodywork?*
Google
Instagram/Facebook
Referred by a friend or family member
Referred by a medical professional
Youtube

If you were referred by a friend, that friend may be entitled to a referral credit so please add their name below: *
Are you currently under Medical care?*
No
Yes
Do you receive regular treatment from a Chiropractor or Physical Therapist currently?*
No
Yes
Are you currently pregnant?*
No
Yes
N/A
Are you currently taking prescription medications? If yes, please list them next.*
No
Yes

Please list prescription medications or if none to list, write N/A *
Are you currently in pain?*
No
Yes

If yes, does anything, including a change of position that you are standing sitting or laying in make the pain better or worse?

Please explain the area of your pain/discomfort. Or N/A *
Do you have any orthopedic injuries? *
No
Yes
Have you had any past injuries that we should be aware of?*
No
Yes

If yes, please explain. If no, N/A
Please indicate any of the following that apply to you:*
Allergies
Arthritis/Tendonitis
Blood Clots
Cancer
Circulation Problems
Diabetes
Fibromyalgia
Headaches/Migraines
Heart Attack
High/Low Blood Pressure
Joint Replacement Surgery
Kidney Dysfunction
Lack of Reduced Sensation
Neuropathy
Paralysis
Skin Conditions
Sprains/Strains
Stroke
TMJ
Varicose Veins
N/A

If you checked any conditions above, please explain.
Are you, in general, an active individual that participates in a sport or physical activity regularly or are you a professional, semi professional or retired athlete?*
Active in a sport or exercise regularly
Semi pro athlete
Professional athlete
Retired Athlete
Not active regularly. Not a retired athlete.
Our goal is to get you out of pain and back to homeostasis as quickly as possible. That requires our team effort. Do you understand that our program is not only manual therapy but includes an assessment for the source of the issue, since the origin of the issue is never where the pain is, and corrective movements and education that increases your rate of healing? If we were able to get you out of pain, would you be willing to put in effort into a customized program designed specifically for you to get out of pain in the quickest path?*
No
Yes
First Client Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
If you are interested in mobility and injury prevention tips by e-mail.
Release of Photos and Videos
I will allow Sportbodywork to use photos or videos for educational/training purposes (this question does not apply to minors)*
No
Yes
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
We are not magicians, but if you could wave a magic wand and fix one thing as it relates to muscle and joint pain in your body, what would it be?

My #1 complaint is: *
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
What is your current level of daily pain ? (1 being tolerable 10 being excruciating)
Click to customize multiple option*
1
2
3
4
5
6
7
8
9
10

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above. Parent will accompany a minor to all of their treatments and remain in the treatment room during the appointment.




By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
How were you referred to Sportbodywork?*
Google
Instagram/Facebook
Referred by a friend or family member
Referred by a medical professional
Youtube

If you were referred by a friend, that friend may be entitled to a referral credit so please add their name below: *
Are you currently under Medical care?*
No
Yes
Do you receive regular treatment from a Chiropractor or Physical Therapist currently?*
No
Yes
Are you currently pregnant?*
No
Yes
N/A
Are you currently taking prescription medications? If yes, please list them next.*
No
Yes

Please list prescription medications or if none to list, write N/A *
Are you currently in pain?*
No
Yes

If yes, does anything, including a change of position that you are standing sitting or laying in make the pain better or worse?

Please explain the area of your pain/discomfort. Or N/A *
Do you have any orthopedic injuries? *
No
Yes
Have you had any past injuries that we should be aware of?*
No
Yes

If yes, please explain. If no, N/A
Please indicate any of the following that apply to you:*
Allergies
Arthritis/Tendonitis
Blood Clots
Cancer
Circulation Problems
Diabetes
Fibromyalgia
Headaches/Migraines
Heart Attack
High/Low Blood Pressure
Joint Replacement Surgery
Kidney Dysfunction
Lack of Reduced Sensation
Neuropathy
Paralysis
Skin Conditions
Sprains/Strains
Stroke
TMJ
Varicose Veins
N/A

If you checked any conditions above, please explain.
Are you, in general, an active individual that participates in a sport or physical activity regularly or are you a professional, semi professional or retired athlete?*
Active in a sport or exercise regularly
Semi pro athlete
Professional athlete
Retired Athlete
Not active regularly. Not a retired athlete.
Our goal is to get you out of pain and back to homeostasis as quickly as possible. That requires our team effort. Do you understand that our program is not only manual therapy but includes an assessment for the source of the issue, since the origin of the issue is never where the pain is, and corrective movements and education that increases your rate of healing? If we were able to get you out of pain, would you be willing to put in effort into a customized program designed specifically for you to get out of pain in the quickest path?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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