New: Holistic Introductory Intake Form

Thank you for taking the time to complete this intake form. It’s a foundational part of how I prepare to serve you with safety, clarity, and care.

This form is required before your appointment and may take up to 30 minutes to complete. Please plan accordingly and answer each question as honestly and thoroughly as you can. The purpose of these questions is to gain a full picture of how your body is currently functioning — so I can support you safely, comfortably, and with the most effective strategies for your goals.

Do not leave any questions blank. If a question doesn’t apply to you, simply write N/A.
Be clear and specific. If something is a concern, describe what it is and where it affects you.
This form does not auto-save. If you need to pause, you’ll need to re-enter the form and begin again.

If this form is not submitted at least 10 days prior to your appointment, the reservation will be rescheduled.

Thank you for your honesty and time — I look forward to working with you.

With care,
Victoria R. Hackworth
Holistic Therapeutic Massage Therapist, S.T.M.
NC LMBT #13635

What is your main reason for coming to S.T.M. at this time in your life? (What are you seeking to change, ease, or support?)

I want to create a long-term path toward healthy aging and mobility into my 90’s.

I need a grounded, stress-free zone to recharge and realign myself regularly.

I’m seeking tension relief and targeted tune-ups for specific areas of discomfort.

Your nervous system controls everything — from movement to stress responses. Understanding how it functions helps me support your ability to relax, feel safe, and restore naturally.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

Your heart and blood vessels deliver oxygen and nutrients to every part of your body. These questions ensure treatments are safe and support your circulation gently and effectively.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

Your lymphatic system clears waste and supports your immune health. Knowing how it’s functioning helps me guide treatments that support detox and reduce inflammation.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

Breathing well is essential for life and relaxation. These questions help to understand how your lungs are working and if your environment or history might affect how your body receives care.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

Your gut plays a huge role in your energy, immunity, and emotional health. These questions help to uncover patterns that may affect your comfort or recovery.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

Your muscles, bones, and joints determine how you move and feel each day. These questions guide me in relieving tension and supporting your alignment and function.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

Joint Replacement

Hardware (Pins, metal plates, metal bars)

Osteoarthritis

Chronic Numbness

Nerve Entrapment

Degeneration of bones

Degeneration of tendons

Degeneration of muscles

The Integumentory, your skin, protects and reflects your inner health. These questions ensure your comfort, avoid sensitivities, and help me work with the fascia just beneath the surface.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

Hormones influence your mood, energy, metabolism, and sleep. Understanding your rhythms helps me work in sync with your body’s natural timing and needs.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

The Reproductive system plays a vital role and connects with nearly every other part of the body — from hormones and digestion to energy and circulation. Understanding any patterns here helps me support your overall wellbeing with clarity and care.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

The Energetic system reflects how your body perceives and responds to the world. These questions help to work with your energy and awareness in gentle, restorative ways.

Do you experience or have been diagnosed with any of the following? Select any of the following that applies and comment when/where it occured, to you currently:

Detox and elimination are vital indicators of internal balance. Patterns in these systems often reflect the health and function of deeper organs — offering insight into how your body is processing, releasing, and maintaining balance. These questions help identify habits or blocks that may affect your whole-body wellness.