Intrinsic Mind Holistic Health & Wellness
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Student Survey 2020
Thai Yoga Massage Health Questionnaire
Indicates required field
Date of Birth
Have you had a Thai Yoga Massage before?
If yes, please tell us about your experience
Please indicate if you have any of the conditions listed below
Allergies and Asthma
Active infectious disease (ex fever, cough etc)
Cervical Spine Problems
Coagulation & Platelets
Anticoagulant therapy - Coumadin, Warfarin or Heparin
Other platelets or coagulation
Brain or aortic aneurysms
High blood pressure
Deep vein thrombosis
Soft tissue contraindication
Open wounds and cuts
Other - Please Describe
Do you hold any TENSION in your body, if so where?
Do you have any CRAMPING in your body, if so where?
Do you have any NUMBNESS in your body, if so where?
Do you have any PAIN in your body, if so where?
Do you have any MOVEMENT RESTRICTIONS for us to be made aware of, if so where?
Do you have any additional comments that you would like to inform your Thai Yoga Massage Practitioner prior to your appointment?
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
I hereby consent to this massage
3/373 Glen Osmond Road, Glen Osmond
0406 939 090
0438 520 219
We aim to respond within 24 hours
Intrinsic mind wellness
"Believe, Achieve, Succeed"
Copyright © Leisa Timms & Jen Ince 2016.
Intrinsic Mind Holistic Health & Wellness Pty. Ltd. All Rights Reserved