Name
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First Name
Last Name
Pronoun of choice
Date
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Email Address
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Phone
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Address
Address 1
Address 2
City
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Age
Referred By
What is your occupation?
What would you like to focus on in your Aston® Kinetics session (i.e. posture, movement, efficiency, stress relief, athletic performance, etc.)?
Please describe any areas of pain, stress, fatigue or restricted movement that you are experiencing that have led you to Aston® Kinetics:
What factors seem to easily aggravate this problem?
Illnesses, surgeries and/or injuries history:
Please answer the following questions in as much detail as possible. The information will help to clarify your areas of interest and will assist in the development of a teaching sequence tailored to your specific needs. The information will be used for need determination only, not diagnosis. Please describe your pertinent medical history, with dates whenever possible.
What have Physician(s) or Practitioners provided in terms of diagnosis or treatment?
Are you currently taking any medications?
Check any of the following that apply to your person medical history:
What other kind of medical care or body disciplines are you currently involved in, if any, and with whom?
What is your occupation and what kind of activities do you perform while working, which seem to stress certain areas of your body? Please describe:
Is there anything else that you would like your Aston-Patterning® Practitioner to know about you?
Do you understand that Aston-Patterning® is not a medical procedure and is not a substitute for medical diagnosis (e.g. We do not submit our forms and invoices for insurance billing)?
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I understand that Aston Kinetics, The Aston Paradigm Corporation, its staff and students (“Released Parties”) do not diagnose illness or disease and do not prescribe medical treatment or pharmaceuticals. I understand that Aston Kinetics is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have. I have stated all my known physical conditions and medications, and I will keep Aston Kinetics updated on any changes. I agree to indemnify and hold the Released Parties harmless from all losses, liabilities, damages, costs or expenses (including but not limited to reasonable attorneys’ fees and other litigation costs and expenses) incurred by any of the Released Parties as a result of any claims or suits that I (or anyone claiming by, under or through me) may bring against any of the Released Parties to recover any losses, liabilities, costs, damages, or expenses which arise during or result from my participation in the activity, regardless of whether or not caused in whole or in part by the negligence or other fault of any of the Released Parties. I have carefully read and reviewed this Waiver, Release and Hold Harmless Agreement. I understand it fully and I execute it voluntarily.
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Please type your name. You will be asked to sign before your session.
First Name
Last Name
