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* 1. Name

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* 2. What are your goals for receiving bodywork?
(Pain relief, relaxation, improved posture, maintenance, etc.)

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* 3. Please list any injuries, recent surgeries and current health conditions.

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* 4. Please list any medications you are currently taking.

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* 5. Are you currently experiencing pain? If so, please explain.

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* 6. Are there any areas you would like me to provide extra focus or any areas you would like me to completely avoid?

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* 7. Do you know what style of work you prefer?

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* 8. Other Preferences (check all that apply)

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* 9. Emergency Contact

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* 10. Consent for Treatment: If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding this, I give my consent to receive care.

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