The general intake form is for Thai bodywork, gua sha facial massage, and herbal oil abhyanga. Name * First Name Last Name Preferred pronouns Occupation Reason for visit Are you sensitive to pressure in any areas? What types of self care do you part take in? Please share any previous injuries or surgeries Do you have any allergies? Have you ever been treated for cancer? Anything else I should know about your body? Check all that apply to you Anxiety or depression High blood pressure Low blood pressure Herniated or bulging discs Diabetes Pregnancy Varicose Veins Numbness Seizure or Epilepsy I have filled out all information to the best of my knowledge. I understand Massage Therapy is not meant to take the place of any medical examination. Massage Therapist do not diagnosis ,prescribe or treat any physical/mental illness. At anytime if I feel uncomfortable during a session I will let my provider know immediately so the pressure or strokes can be adjusted. It is my responsibility to keep the practitioner updated on any medical changes, and there is no liability on the practitioner if I fail to do so. Also any sexual references or advances will not be tolerated and session will be terminated immediately in which I will be liable for full payment of the session. * I have read the agreement above Thank you!
