Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
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Will you be needing an extra scheduling reminder with email (via cell/text, home or work phone)?
SELECT
YES
NO
If YES, please indicate which is the best way to contact you.
Mobile
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(###)
###
####
Home
(###)
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Work
(###)
###
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Occupation
Date of Birth
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MM
DD
YYYY
Emergency Contact Name
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Emergency Contact Phone
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(###)
###
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FEMALE ONLY: Are you pregnant?
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SELECT
Yes
No
FEMALE ONLY: If Yes, congratulations! How many weeks are you? If still in 1st Trimester (first 12 weeks) of pregnancy, please wait until after your 1st Trimester to schedule your PreNatal Care. Thank you.
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Have you had a Professional Massage before?
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SELECT
Yes
No
If so, what form(s) of therapy have you received within the past year and how would you describe your experience(s)?
What made you decide to have a professional massage today?
SELECT
Relaxation
Circulation
Pain Management
Clinical Body Corrective
Wellness/Self-Care
Promotional Offer
Other
If OTHER, please explain:
How is your stress level? [ 1=low, 10=high ]
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SELECT
1
2
3
4
5
6
7
8
9
10
Chief Complaint:
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What area(s) do you tend to hold stress? Area(s) of concern you prefer focus (highest priority) therapy on today?
Describe Level of Discomfort from a scale of 1-10, 10 being the most severe. Describe Type, Pain or Stress; Stress Tension or Stress Tightness (Tension Stress comes from tensile stress/strain, such as pulling a rope. Tension is vectoral/rectilinear in nature. Tightness Stress typically refers to contraction/shortening/shrinking/reduction of a range of motion on a designated plane, field, or given dimension). Do you feel Pain or Stress? If Stress, what type? How often? What activity(ies) make you notice the area(s) most? Is the area anterior or posterior (front or back)? Are symptom(s) of discomfort sharp or radiating?
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Do you have any allergy(ies)?
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SELECT
Yes
No
If YES, what are you allergic to?
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Do you smoke?
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SELECT
Yes
No
If YES, how much and how often?
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Do you have regular caffeine intake?
*
SELECT
Yes
No
If YES, how much and how often?
Do you drink beverage(s) containing Alcohol?
*
SELECT
YES
NO
If YES, how much and how often?
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Do you exercise?
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SELECT
Yes
No
If YES, how often do you exercise?
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SELECT
Low
Moderate
High
Injury(ies) or Accident(s)? When? Doctor(s) diagnosis(ses) or treatment(s)? Any surgical procedure(s), medical implant(s), device(s), prosthetic(s), tissue(s) designed to replace missing body part(s) including breast(s), deliver medication(s), monitor body function(s), or provide support to organ(s) and tissue(s) I need to be aware of?
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*
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What activity(ies) worsen pain, if any?
Are you on any prescribed medication(s) and/or over the counter drug(s) and/or supplement(s)?
*
SELECT
Yes
No
If YES, please list medication(s) and/or supplement(s):
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Health Guideline Precaution(s): As a Nationally Health Regulated Licensed Massage Therapist, "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., the focus is on promoting health and Do No Harm, ensuring continued best practice(s) for maintaining a healthy and safe environment for "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., and client(s)/participant(s) safety. Massage Therapy should be avoided when there is a communicable disease(s) for the good of both the client/participant and the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT.; including all client(s)/participant(s) and the place of practice. For example, client(s)/participant(s) with Athlete's Foot can have the fungus spread to other area(s) of the body, as well as to the therapist. Other example(s) of communicable condition(s) include, but are not limited to, viral illness(es) caused by the Herpes Virus - Chicken Pox, Jock Itch, Ringworm, Scabies, Warts, Shingles, Cold Sores - or Bacterial Infection(s). Other contraindication(s) to avoid Massage Therapy are open sore(s) or wound(s) which are source(s) of transmission(s). And in the the case of noncommunicable condition(s), contact with open, broken skin (sores/wounds) can cause pain and irritation, possibly causing further aggravation and infection. By proceeding you are certifying that you are SAFE To Receive Massage Therapy and can Attest you have No Communicable Disease(s) or open, broken skin (sores/wounds), are not sick, do not have the flu or a fever, are not suffering from any symptom(s) including nausea, do not have other case(s) such as blood clots, inflammation, uncontrolled hypertension, kidney or liver condition(s), broken bone(s), cancer etc., and have No Other Major Contraindication(s) not mentioned here etc., and are not taking or using alcohol, marijuana, or over the counter painkiller(s) before a massage; safety is crucial and a relaxing experience where you receive the greatest benefit from your therapy is priority, it is strongly recommended not to use alcohol or drug(s) before a massage. For clients/participants with prescription painkiller(s), please continue to follow your doctor(s) treatment and advice, but plan your massage when painkiller(s) are at their lowest. Please do not schedule a massage directly after taking over the counter or prescription medication(s), or other substance(s) that decrease the benefit of your therapy and make it specifically unsafe, and always let the Therapist know of any change(s) in medication(s), doctor(s) treatment(s), record(s), medication(s) information(s), etc.,. Please Check all medical and/or other condition(s) that apply:
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Please be informed that I understand my limitation(s) and do not practice outside my scope. Currently, I do not have specialized training for Oncology Massage and cannot in good ethics provide a service to the public I am not qualified for, including Oncology Massage for patient(s) actively receiving treatment. I can provide light, relaxing Therapeutic Massage with complimentary Reiki (I&II CE) for patients in remission and/or if you are a patient actively receiving cancer treatment and would still like to see me, I can accommodate Reiki Session(s) Only or Reiki Session(s) with a Foot Reflexology/Ritual with a Doctor(s) clearance for treatment.
*How did you hear about me?
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INFORMED CONSENT FOR PARTICIPATION, Confidential Initial Clinic Client Consultation: By typing my name below and submitting this Initial Clinic Client Consultation Form, I certify and understand it is a legitimate record of my written signature, agreement, approval, and all stated information is accurate, true to my knowledge, confidential, and will not be shared without my express written consent unless such information is required by the Activity Waiver Legal Release Form Term(s). I understand the Activity Waiver Legal Release Form is a requirement with the Initial Clinic Client Consultation Form to receive valuable quality service(s), activity(ies), content(s), good(s), event(s) and offering(s). I understand all information stated serve(s) to provide professional care on a professional level for complementary alternative medicine in manual body corrective work for soft tissue and muscular therapy and receive valuable quality service(s), activity(ies), content(s), good(s), event(s) and offering(s) that are in accordance with health and safety regulation(s) within reason and to the best of the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., ability(ies), that is fair or reasonable, and not extreme for all party(ies) involved. I understand that if the information I have given on this form has changed and need(s) to be updated, I will immediately notify the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT. I understand proper, respectful, healthy hygiene and etiquette is a must at all times and any inappropriate misconduct may be reason to end service(s). I understand the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., does not diagnose or treat a health problem(s) or disease(s), and those seeking personal medical advice should consult with a licensed physician; a recognized doctor or other qualified health provider regarding medical condition(s). I understand all content on Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT., is educational, for informational purposes only and does not constitute providing medical advice or medical service(s). I understand my Right of Refusal and the Right of Refusal of the "Activity Provider(s)" BodyWork Health Practitioner(s) Novum LL Bliss LLC / Aum Body Bliss LLC c/o Novum LaLuna LMT. I understand payment is required upon render of service(s) unless otherwise noted, i.e., complimentary student clinic offering(s). I understand tardiness shortens service(s), activity(ies), offering(s) times. I understand I have a 24 hour grace period to provide notice for any cancellation(s), no-show(s), rescheduling etc., after which time I will be held liable for full charge(s) and/or incidence(s) of inconvenience(s) which may result in termination or extinguishment of further continuation of rendered service(s). I agree to all term(s) and condition(s).
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