Massage Pre-Appointment Consultation

Pre-Appointment Consultation

Massage Services
Thank you for completing this Pre-Appointment Consultation. This will enable your service provider to be more prepared for your appointment.
Name*

First NameLast Name
Birthdate

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Who is your appointment with?
Existing Appointment Date

MonthDayYear
Date
What prompted this appointment?
Well-Being Questions - Please check any conditions that currently apply:

ArthritisDiabetesRecent SurgeryPlanters FasciitisThin SkinSensitive KneesVaricose VeinsPregnancyDeep Vein ThrombosisOther
Pregnancy: How many Months
Pregnancy: Due Date

MonthDayYear
Date
Diabetes: Which Type
Are you currently under the care of a Health Care Professional for injuries or ongoing medical treatment

YesNo
Please Explain:
Are you currently taking any medication?

YesNo
Please list medications
Is there anything else about your health history you think would be useful for your massage therapist to know to plan a safe and effective service for you?
We reserve the right to refrain from providing a massage service until written permission is given by your medical professional
Lifestyle Section
Do you smoke?

YesNo
Do you exercise regularly

YesNo
Do you wear contact lenses?

YesNo
Do you wear dentures?

YesNo
Do you wear a hearing aid?

YesNo
Do you have implants?

YesNo
Implants: Where are they located?
Aromatherapy - What’s Your Elemental Nature?
The five elements represent the five different forces that are present within all living things. When they are in balance, we look and feel healthy, vital, and radiant. At Aveda, we use a variety of sensory techniques to bring your Elemental Nature back into balance. To assist your therapist in choosing an aroma that balances your Elemental Nature, please chose one condition from each category that most accurately describes what has been most true for you today.

Please choose one from each topic:
Body Temperature

Infinity: Tend to feel comfortableAir: Tend to feel coldFire: Tend to feel warm/hotWater: Tend to feel coolEarth: Tend to feel moderate
Hair/Scalp

Infinity: Thin, dull, split ends, normal to dry scalpAir: Fine, dandruff, dry scalpFire: Fine, premature grays, sensitive scalpWater: Lustrus, OilyEarth: Thick, Heavy, somewhat oily
Stress Response

Infinity: NervousnessAir: Anxious, WorryingFire: Anger, IrritabilityWater: EmotionalityEarth: Withdrawal
Energy Level

Infinity: Tends to be highAir: Sporadic, tendency toward extremesFire: Consistent, steady, strongWater: Slow but consistentEarth: Tends to be low
Body Type

Infinity: PetiteAir: Tall and thinFire: AthleticWater: HeavyEarth: Large and broad sholdered
Sleep Pattern

Infinity: Light sleeper/awaken easilyAir: Trend to have frequent insomniaFire: Solid Sleeper, can function well on less than six hours sleepWater: Tend to sleep deeply/heavilyEarth: Tend to sleep deeply/heavily, needs more than eight hours sleep
Pattern of Activity

Infinity: Mildly dislike routinesAir: Strongly dislike routinesFire: Likes routinesWater: Needs routinesEarth: Always follow a routine
Thought Process

Infinity: Think quickly and oftenAir: Learn new information quickly but forget things easilyFire: Focus well and have sharp intellectWater: Learn new Information slowlyEarth: Have a great long term memory
Any other questions or comments for your massage therapist?
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage 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 that I am aware of. I understand that massage therapists 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 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. It is my choice to receive massage therapy. I understand that the information given above is strictly confidential and will be used for no other purpose than to assist the massage therapist in providing a suitable massage that would take into consideration my specific requirements. I also understand that failure on my part to disclose information could result in injury and/or illness and I hereby release Sandalwood Salon and Spa and Aveda Corporation from any claims resulting from such. Any information provided to me by the massage therapist is for general educational purposes only and is not intended for any medical or therapeutic purpose.
Signature*

Clear
Signature Date*

MonthDayYear
Date
That's it! Thank you for participating. We look forward to seeing you soon!

Sandalwood Salon and Spa

360-647-5046
Should be Empty: