Innate Sense Intake form
ALL INFORMATION GIVEN IS NOT SHARED OR SOLD TO ANYONE!!
*Within the last year have you been under a physician‛s care? yes* no
*If yes, specify
*Have you ever undergone Surgery? yes* no
*If yes, explain:
List any medications, supplements, vitamins, diuretics, slimming tablets, etc. that you take regularly.
List any ailments you may have (diabetes, high blood pressure)
What is your occupation?
What repetitive motion or non-motion does your work require (ex: sitting, lifting)
*Do you smoke?
*Do you exercise regularly?
*if yes how often:
*Do you follow a restricted diet?
*if so specify:
Do you have any allergies or sensitivities to any nuts/fruits or oils?
*Do you wear contact lenses?
*Are you pregnant or trying to get pregnant?
*if yes, # of months:
Rate your level of stress on a scale of 1-6 (1=low, 6=high)
*Is there any infectious disease I should be aware of?
*if yes, please list:
*Have you ever had a professional massage?
if yes, date of last massage:
What do you love or dislike in your massage session?
What areas of your body needs more focus work?
Are you ticklish?
*Do you feel massage should be a part of your health maintenance program?
*How well do you take care of yourself?
1 2 3 4 5 6 7 8 9 10
*Rate your level of Satisfaction and PEACE you feel in each area of your life (1 = low, 6 = High)
I know and Understand the following
I , understand that massage therapy given here is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation and energy flow. 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 understand that the massage therapist does not diagnose illness, disease or other physical mental disorder. As such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulations. It has been made very clear to me that this massage therapy is not substitute for medical exams and/or diagnosis and that it is recommended that I see a physician for any ailment that I may have. Because a massage therapist must be aware of any existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on my health. I understand that any soreness due to deep tissue work is not an injury but do to the release of adhesions and my body readjusting. I understand that in an Ashiatsu Oriental Bar Therapy session I am receiving deep compression therapy. I will not hold any INDEPENDENT CONTRACTOR of Innate Sense, or Innate Sense Wellness Solutions, LLC. responsible for any discomfort after my session, or press charges for any bodily harm. I understand that each therapist @ Innate Sense is an independent contractor and not an employee of Innate Sense Wellness Solutions, LLC. 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. I understand that my email will be added to Innate Sense online email list for Innate Sense newsletters but will not be sold or shared to any other businesses or companies. I understand that full payment of services is due at the end of each session. I understand that Signing this is a release of liability.