Cathay ™ Massage Intake Form

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Cathay ™ Health History and Entrance Form

A complete health history helps us ensure it is safe to provide you with a massage treatment.

Please let us know if your status changes so we can update your form.

All information given to us is confidential.
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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Mobile Phone Number* This field is required.
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What is the reason for your visit today?* This field is required.
Pain
Tension
Relaxation
Headaches/Migraines
Stress
Muscle Spasm
Injuries
Inflammation
Fatigue
Anxiety
Insomnia
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Please check all the health conditions that apply to you.
Arthritis
Cancer
Digestive Disorders
Fibromyalgia
Plantar Fasciitis
Pregnancy
Sciatica
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Please indicate areas you would like us to focus on.
Arms & Hands
Back
Feet
Gluteal Region
Head
Legs
Neck
Shoulders
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Lifestyle
On my feet
Sedentary
Sports/Athletic
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What kind of pressure do you prefer?* This field is required.
LIGHT - Mostly long, sweeping, relaxing, gentle strokes; chiefly affects superficial tissue layers
MEDIUM - Incorporates techniques such as kneading & friction to target more specific muscles
FIRM - This intense pressure targets deeper muscle layers, incorporating more therapeutic techniques
DEEP: The most heavy-handed of the pressures, involves skilled techniques affecting entire muscle groups & can be painful
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Consent:

I understand that the massage therapy I receive is provided for the purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the massage therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage therapy is not a substitute for medical examination, diagnosis or treatment and that I should see a physician or qualified medical specialist for any physical or medical ailment of which I am aware. I understand massage therapy should not be performed under certain medical conditions, and I affirm that I have stated all my known medical conditions and have answered all questions accurately.

I understand that Cathay massothérapie & acupuncture ™ reserves the right to refuse to administer services at their sole discretion. I have read and fully understand this form in its entirety. If at any time there are changes in the information given, or in my condition, I will notify my therapist, and update this form before receiving additional massages.

My signature below affirms that I have read and agreed to the foregoing.
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Signature* This field is required.
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