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HEALTH INTAKE FORM

Birth Date
Month
Day
Year

Health History Questions

How would you rate your current stress level? (1 = Low, 10 = High)
Do you have any allergies?
Are you allergic to any of the following?
Are you currently taking any blood thinners?
Do you have deep vein thrombosis or DVT?

An inflamed blood clot within a vein, usually in the leg, is called thrombophlebitis. Symptoms include redness, swelling, tenderness and pain along the course of a vein, which may be near the surface of the skin (superficial phlebitis) or deep within a muscle (deep vein thrombosis or DVT).

Do you have any sensitivity issues with heat or steam?
Have you had OR currently have Cancer?
Have you had any lymph nodes removed?
Are you diabetic?
If yes, is your condition being managed?
Have you had a fever in the last 48 hours?
Do you have any cuts, sores, or open wounds?
Do you have any herniated discs, fractures, implants, or osteoporosis issues?

COVID-19 Liability Release

By signing below, you acknowledge that you understand the risks associated with COVID-19 and agree to follow all safety protocols set forth by the therapist. You release the therapist from any liability related to COVID-19 exposure during your session.

Massage-Specific Questions

Have you received a massage before?
What are your primary goals for this massage?
Do you have any specific areas of concern or discomfort?
Do you want me to EXCLUDE (not use or perform) any of these extras?
Are there any other areas you would like me to avoid during the massage?

Client Responsibility

It is your responsibility to complete this form honestly and to the best of your ability. By booking and receiving services, you confirm that you have read, understood, and agree to the terms outlined in this form.

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