Luminous Online & Mobile Appointment & Record Form
Mobile Massage Clients, Please Ensure you have 2 sheets and 1 pillowcase for your massage session.
Name
*
First Name
Last Name
Appointment
Please indicate if you have a prearranged date and time
Date / Time
Additional Information:
Length of your massage?
*
A) 60 min ($107)
B) 90 min ($155)
C) 45 min ($97)
D) 30 min ($60)
1. What type of massage would you like?
*
A) Tension Relief (Medium - Deep Pressure, Trigger Point Release, Assisted Stretch)
B) Lymphatic Drainage
C) Relaxation (Light - Medium Pressure)
D) Therapeutic (Relief of known or unknown Injury)
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Tension Relief
Would you like headache relief?
Yes
No
Would you like cupping?
Yes
No
If you have answered "No" to the following two questions, Please submit your form, otherwise click next.
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Submit
Next
Lymphatic Drainage Massage
Where is your inflammation / Lymph build-up located
A) Head
B) Upper Body
C) Lower Body
D) Upper and Lower Body
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Relaxation Massage
Would you like hot stones?
A) Yes
B) No
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Submit
Next
Therapeutic Massage
Add Any Additional Information If Necessary?
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Submit
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Area Of Concern
Area of concern:
*
1) Hand, Wrist, Arm
2) Neck, Shoulder
3) Hip, Pelvis
4) Foot, Ankle, Shin, Knee
5) Butt, Hamstrings
6) Mid, Low Back
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6.0 Back Pain
6.1) Do you feel wobbly or unstable when walking or climbing?
A) Yes
B) No
6.2) Do you experience radiating pain, down to your knee?
A) Yes
B) No
6.3) Do you experience poor balance or difficulty getting up after sitting?
A) Yes
B) No
6.4) Do you experience low back stiffness or spasms?
Yes
No
Would you like cupping?
A) Yes
B) No
Please Submit your form.
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5- Butt, Hamstrings
5.1) Do you experience radiating pain down your thigh, calf and foot?, pain after sitting? Or pain when walking up stairs or inclines? (yes if any apply)
A) Yes
B) No
Would you like cupping?
A) Yes
B) No
Back
Submit
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4.0 Ankle, Shin, Knee
4.1) Are you experiencing pain anywhere in the following areas (Ankle, shins, knee)?
A) Yes
B) No
Would you like cupping?
A) Yes
B) No
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3.0 Hip, Pelvis / Groin
3.1) Area you experiencing?
A) Soreness
B) Pain
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2.0 Neck, Shoulder
2.1) Where is your discomfort?
A) Neck
B) Shoulder
Neck and Shoulder
2.2) When do you experience discomfort?
A) With movement
B) Constant
Would you like cupping?
A) Yes
B) No
Back
Submit
Next
1.0 Hand, Wrist, Arm
1.0) Do you have difficulty lifting your hands over your head?
A) Yes
B) No
Would you like cupping?
A) Yes
B) No
Submit
Should be Empty: