Intrinsic Mind Holistic Health & Wellness
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Thai Yoga Massage Health Questionnaire
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Indicates required field
Name
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First
Last
Email
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Phone Number
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Date of Birth
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Have you had a Thai Yoga Massage before?
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No
Yes
If yes, please tell us about your experience
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Please indicate if you have any of the conditions listed below
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Allergies and Asthma
Active infectious disease (ex fever, cough etc)
Cancer
Cervical Spine Problems
Hernia
Pregnancy
Rheumatoid Arthritis
Recent Surgery
Coagulation & Platelets
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Hemophilia
Anticoagulant therapy - Coumadin, Warfarin or Heparin
Other platelets or coagulation
Cardiovascular Disease
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Brain or aortic aneurysms
Heart disease
High blood pressure
Stroke
Deep vein thrombosis
Joint probems
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Fractures
Previous dislocations
Soft tissue contraindication
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Open wounds and cuts
Skin Disease
Other - Please Describe
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Do you hold any TENSION in your body, if so where?
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Do you have any CRAMPING in your body, if so where?
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Do you have any NUMBNESS in your body, if so where?
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Do you have any PAIN in your body, if so where?
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Do you have any MOVEMENT RESTRICTIONS for us to be made aware of, if so where?
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Do you have any additional comments that you would like to inform your Thai Yoga Massage Practitioner prior to your appointment?
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Consent for Thai Yoga Massage
I understand that the purpose of a Thai Yoga Massage is for relaxation and it is not meant to diagnose or treat any illness, disease or any other physical or mental disorder, injury or condition. I have informed my Thai Yoga Massage practitioner about my state of health and I have transmitted any recommendations and restrictions on the part of my medical doctor or therapist insofar as Thai Yoga massage is concerned
I have answered all the questions truthfully and to the best of my ability
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Yes
No
I hereby consent to this massage
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Yes
No
Date
*
Submit