Name
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First Name
Last Name
Email
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Phone
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(###)
###
####
Are you new to movement, meditation, and/or massage?
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Yes
No
What brings you in for our session today?
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What particular goals/focus area are we hoping to address today?
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Are you comfortable working the following areas?
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(check all that apply....)
Are there any areas you would like to avoid today?
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What kind of pressure would you like applied during your bodywork session today?
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Is there anything we really want to make sure to address in our session today?
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Are you pregnant or nursing?
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Yes
No
Are you presently under the care of a physician?
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Yes
No
If YES, please explain and list any conditions you are currently being treated for:
Are you currently on any medications including blood thinners, NSAIDS, or pain management drugs?
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Yes
No
If YES, please list so we can make necessary adjustments to insure a safe session:
Have you had any injuries, surgeries, or serious illnesses in the past 6 months?
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Yes
No
If Yes, please describe:
Do you have any allergies/skin sensitivities we should be cautious of in our session today?
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What repetitive motions do you perform throughout your day or in your workplace? List most frequent practices and postures below:
Do you experience any of the following on a regular basis?
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Do you have any of the following MUSCULOSKELETAL conditions?
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Have you had any CIRCULATORY conditions in the last 6 months?
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Have you had any of the following RESPIRATORY conditions in the last 6 months?
Do you have any of the following NERVOUS SYSTEM conditions currently?
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Have you had any of the following SKIN CONDITIONS in the last 6 months?
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Is there anything else associated with your bodymind wellness that might effect your session today?
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If Yes, please explain so that we can create the best experience around your needs:
I understand treatment(s) are to reduce stress & muscle tension. If I experience pain or discomfort during a session I will immediately tell my practitioner to adjust stokes, pressure, or draping to my comfort. I also understand these treatments are NOT a substitution for medical attention and that I should seek a physician for ailments I am currently aware of. Massage is contraindicated under certain medical conditions and I have been honest and accurate about information provided. Initial below if you understand and agree:
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I understand that is is normal to feel some soreness or bruising after a massage, this should resolve in a few days and can be helped by light stretching and plenty of water to avoid dehydration.
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I agree my signature below releases Mountain Moon Health and Wellness and associated providers from all liability associated with my treatment(s). I hold harmless and agree that neither is responsible for a negative reaction due to selected services. Please sign below if you agree and understand:
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