All information is kept private & confidential

First and last name*

Occupation *

Mobile number*

Email address

Address

Apartment, suite or unit number

City

Emergency Contact Information:*

Emergency contact phone number *

How did you hear about Ya'axché?*

Have you received a massage before?*

How long ago was your last massage?*

Reasons for seeking massage? (relaxation, injury, etc.)*

Typical activities of daily living (affected by condition?):*

Do you have a physician referral with diagnosis codes?

Do you have special needs I should prepare for:*

What do you do for stress reduction?*

What other activities do you practice for your wellness ? *

What results do you expect from this massage session *

What is your primary concern today ?*

When was the onset of primary concern?*

Is there any area of your body that you prefer not being massaged?*

Do you have any allergies- if yes explain:*

Have you had any accident, injuries, or surgery ?*

If yes, how long ago?*

Are you receiving medical treatment or are you under a doctor's care?*

Are you taking any medications?*

Are you pregnant - if yes- how many weeks?*

Are you having any complications that I should know about your pregnancy ?*

Are you experiencing any conditions such as: heart problems, aneurysm, herniated discs, contagious infection, inflammation, cancer, tumors, ring worm, skin problems, gout, pain, varicose vein*

Are you experiencing conditions such as: rashes, fungus, warts, shingles, numbness, tingling, sleep disorders, low-high blood pressure, whiplash, arthritis, bones-join issues, headaches, sinus-jaw pa*

Are you experiencing TMJ, bursitis, tendonitis, spasms, cramps *

Are you experiencing digestive disorders, diabetes, kidney disease, autoimmune disease, other*

It's my choice to receive massage today. I acknowledge that is NOT a substitute of medical treatment or diagnosis. Please intial*

I agree to communicate with my LMT any time I feel my well being is being is compromised. Please Initial *

I have stated all conditions of which I am aware and I will inform of any changes. Please initial *

I understand that I will be draped appropriately during my massage. Please print full name *

Do you have any questions or concerns:*

Additional Notes*

Date sent*