Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Will you be needing an extra scheduling reminder with email (via cell/text, home or work phone)?

If YES, please indicate which is the best way to contact you.

Cell/Text

Home

Work

Mobile

(###)

###

####

Home

(###)

###

####

Work

(###)

###

####

Occupation

Date of Birth

YYYY

Emergency Contact Name

Emergency Contact Phone

(###)

###

####

FEMALE ONLY: Are you pregnant?

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.

Have you had a Professional Massage before?

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?

If OTHER, please explain:

How is your stress level? [ 1=low, 10=high ]

Chief Complaint:

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?

Area(s) of the body you prefer NOT to receive therapy today?

During a session I am thorough and will include the option to receive work on sensitive area(s) like the gluteal muscle(s) and abdomen upon request. I use professional modesty draping, only exposing the active working area at a time. However, understandably there are area(s) that many would like to avoid including ticklish feet.

Do you have any allergy(ies)?

If YES, what are you allergic to?

Do you smoke?

If YES, how much and how often?

Do you have regular caffeine intake?

If YES, how much and how often?

Do you drink beverage(s) containing Alcohol?

If YES, how much and how often?

Do you exercise?

If YES, how often do you exercise?

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?

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)?

If YES, please list medication(s) and/or supplement(s):

If OTHER, please describe:

This is the opportunity for existing tensions to decrease and to feel more relaxed through the first challenges of getting acquainted with your needs and each other, so relieve inhibitions and tell more about you, if Other.

*How did you hear about me?

Ashiatsu Practice Body Candidate: Would you be interested in being considered for the opportunity to be an Ashiatsu Practice Body and receive a complimentary Student Clinic for Ashiatsu Therapeutic Service(s)?

To be considered as an Ashiatsu Practice Body Candidate you must meet certain criteria(s); be SAFE, relatively fit and in general good health to receive a deeper form of deep tissue from a Health Practitioner of my build and profile. Do you consider yourself a good Ashiatsu Practice Body Candidate and would you like to be informed with upcoming Ashiatsu Practice Body Offering(s)? While I have a history of doing Ashiatsu since I was a little girl (a part of the cultural upbringing I was exposed to), and am a qualified, experienced professional, proficient and competent in my field 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., I am fairly new to the Western Standard(s) of Ashiatsu approved by the National Certification Board for Therapeutic Massage and Bodywork. While Ashiatsu is suitable for almost anyone, during the caterpillar learning phase, I feel it is necessary to be conservative in the mean(s) to deliver a service I am in the process of professionally mastering.

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).

Thank you! Your Initial Clinic Client Intake Form has been submitted. Please also be sure to complete the Activity Waiver Legal Release Form as part of the screening process. You will be contacted after both forms have been reviewed within 48 hours. After the screening process is completed and you have a scheduled Therapy Treatment planned with your Therapist, please plan to be 5-10 minutes early for your scheduled appointment. I look forward to meeting with you!

Remember, if you need to reschedule or cancel your appointment, please contact me at least 24 hours in advance of your scheduled appointment.

You Are Someone’s Reason To Smile.

First, complete this Initial Clinic Client Consultation Form. Next, complete the Activity Waiver Legal Release Form.

CONFIDENTIAL Initial clinic Client Consultation, INFORMED CONSENT FOR PARTICIPATION.

u make me smiley face positive reinforcement because ‘necktie’ stuff can be so blah. blah. blah. Very Dry… Yawns

You Are Someone’s Reason To Smile.

First, complete this Initial Clinic Client Consultation Form. Next, complete the Activity Waiver Legal Release Form.

CONFIDENTIAL Initial clinic Client Consultation, INFORMED CONSENT FOR PARTICIPATION.

u make me smiley face positive reinforcement because ‘necktie’ stuff can be so blah. blah. blah. Very Dry… *Yawns*

u make me smiley face positive reinforcement because ‘necktie’ stuff can be so blah. blah. blah. Very Dry… Yawns