Name
*
First Name
Last Name
Preferred Pronouns
*
Phone number
*
(###)
###
####
Email
*
Occupation
*
Emergency Contact
*
(###)
###
####
What is your goal for today?
*
If you are in pain, please describe this pain and rate it on a scale of 1-10. ( 1 meaning no pain, 10 meaning excruciating constant pain)
*
Please mark any of the following conditions you may have
*
Autoimmune conditions
Please mark any of the following conditions you may have
*
Potentially Contagious Conditions
Please mark any of the following conditions you may have
*
Cardiovascular and Lymphatic Conditions
Please mark any of the following conditions you may have
*
Musculoskeletal Conditions
Please mark any of the following conditions you may have
*
Emotional/Mental Health Related Conditions
Please explain any condition you marked above in further detail if needed
Have you received massage therapy or bodywork before?
*
Is there anything particular you do not like during a massage?
Is there anything you particularly DO like during a massage?
Massage Pressure Preference
*
Conversation preference during a massage
*
Please keep in mind the massage therapist will need to check in occasionally during the session. If at any point you want to change the talking level during your session, please let your massage therapist know.
Are you on any medication(s)? If so, please list them below
*
Do you have any allergies or sensitivities? If so, please list them below
*
Do you exercise? If so, how often?
*
Are you pregnant? If so, how far along?
*
If yes, please book a prenatal massage
Is there anything else about your medical history that you think would be helpful for us to know to ensure we are able to give you a safe abdominal effective massage?
I understand that massage therapy is for the purpose of stress reduction, relief from muscle tension or spasm, or for increasing circulation. I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. The massage therapist does not perform any spinal manipulations or prescribe any form of medical treatment. I will inform the massage therapist about my current condition at the time of each visit.
*
By typing your name below, you confirm that the information provided above is accurate to the best of your knowledge. This serves as your electronic signature. You voluntarily consent to receive massage therapy services and release the practitioner and ACE Collective Salon + Wellness from any liability related to the session.
