Gua Sha Therapy Intake Form Logo
  • All information provided will be kept confidential unless required by law.
    At no given point is information disclosed or shared without a client's written consent.
    Bold titles below with a red asterisk * are required to have information typed into the relevant box. If you have attempted to submit your form and you get "There are errors on the form......", you need to scroll up to the highlighted field to complete before clicking on the submit form button again.
  • There are 2 parts to this form. Both parts must be read, agreed to and signed before submitting.

    1/. "Disclosure and Informed Consent" to having Gua Sha Therapy
    2/. "Health and Medical Information"

  • DISCLOSURE

    Your therapist utilises every available means, including written and verbal intake, and visual and tactile clues in order to give a safe and effective treatment. There is never any anticipation of adverse reactions from Gua Sha therapy but the following is to provide information for the client about Gua Sha and possible outcomes.

    Gua sha (pronouced "gwa-shah") is an East Asian healing technique. A trained professional uses a small, smooth-edged tool to firmly stroke your skin in one direction. This can help improve blood flow and reduce inflammation.

    Gua Sha is a therapeutic technique used by massage therapists, acupuncturists and body-workers for the relief of muscular pain, tension and congestion. These techniques are used to draw out congested fluids and toxins to the surface tissue layers, allowing for fresh blood and lymph circulation. The resolution of stagnation and granulation in the tissues often brings an immediate relief from pain.

    There is a possibility of skin discoloration that can occur from the release and clearing of stagnation and toxins from the body. The reaction is not bruising, but the metabolic waste, toxins, cellular debris, pathogenic factors and other stagnant material/toxins  being drawn to the subcutaneous layers for dissipation by the circulatory system, that have been freed from the underlying tissue and brought to the surface where they can more easily be flushed away. These marks can last anywhere from a few hours to a week and are not tender to the touch.

    To prepare you for treatment, oil will be used on your body. Then a stonelike gua sha massage tool is used to scrape your skin in long, downward strokes. This motion breaks tiny capillaries (blood vessels) under your skin. As a result, you'll see temporary small, red, rash-like dots called “petechiae”.
    As the session goes on, your therapist may slowly add more pressure to the strokes. They should only apply as much pressure as you’re comfortable with. Gua sha shouldn't be painful.

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  • Contraindications:

    1. Haemophilia or other bleeding/clotting disorders
    2. Clients taking blood thinners. (Clients on blood thinners should not experience Gua Sha. If you start taking such medication, please inform the therapist so your treatment plan can be adjusted)
    3. Clients experiencing weakness or those who have been ill
    4. Abdomen and lower back on pregnant women
    5. Diabetics. Especially those with uncontrolled blood sugar as they may not be able to feel pain properly
    6. Those who have circulatory conditions
    7. Gua Sha should not be combined with aggressive ex-foliation, be performed within 4 hours of shaving, or after sunburn.
    8. Recent trauma or injury i.e fractures, sprains and strains should wait until the trauma or injury has fully healed
    9 Those who are unsure if their condition is contraindicated should seek guidance from their primary care physician prior to receiving Gua Sha

  • After Care Recommendations:

    • Drink plenty of water, to help eliminate toxins out of the body. The first time you experience Gua Sha therapy, your body’s immune system can temporarily react to this release as it might with flu-like effects such as nausea and headache. These symptoms will subside in time with rest and water. Water helps to dilute the intensity of the releases.
    • Avoid exposure to cold, wet and/or windy weather conditions, hot/cold showers, baths, steam, saunas, pools, hot tubs and aggressive exercise for 4-6 hours. Exposure to such extremes can produce undesirable effects and you should avoid such situations.
    • Light stretching and range of motion exercises are beneficial.

  • INFORMED CONSENT
    I, * have read and understand all the Gua Sha Therapy information and I agree to allow the therapist to perform Gua Sha. I also agree that I have read, understand and will follow all of the information above for aftercare and will not hold the therapist responsible.
    I understand that bruising, discoloration and/or soreness will likely occur following this treatment and may take days or weeks to fully resolve. I further understand that the above-listed contraindications for Gua Sha therapy and I have informed my therapist of any and all medical conditions, even those not listed as contraindications.

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  • Client Information, Health and Medical History

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  • Touch the black square to select a different colour other than black before drawing.
    With your mouse (pc) or finger (device) draw on the body image using the different sized dots or brushes any areas of discomfort, pain, stiffness, numbness or tingling.

    *** DO NOT CLICK THE "X" NEXT TO THE ARROWS. THIS WILL DELETE THE ENTIRE BODY IMAGE ***

  • Gua Sha Treatment Policies:

    Client services and chart information are confidential. Written authorisation is required from you to release any information.

    • Please turn off your mobile phone for optimal relaxation
    • Your scheduled session is set aside for you. We do not double book appointments
    • Please reschedule your session if you are more than 15 minutes late
    • 24+ hour cancellation notice is required to avoid being charged for your session
    • You will be draped and at no time will genitalia or breast tissue be exposed
    • You will have a consultation with your therapist before any treatment is performed
    • Should the session require, after your therapist has left the room, you may disrobe to your comfort level
    • I understand that my therapist or I may end the session at any time for any reason
    • Inappropriate behaviour will not be tolerated and may be prosecuted to the full extent of the law

  • By signing below, I agree that I have read and understand the following:

    Gua Sha therapy is not a substitute for medical care. If you are experiencing any medical problems and have not seen your medical doctor, I recommend you do so today.

    I understand that all treatments at Howlistic Healing are therapeutic in nature, information has been provided to me about Gua Sha Therapy. I agree to communicate to the therapist any discomfort or draping issues during the session. It has been explained to me that there are contraindications for Gua Sha Therapy. I have fully disclosed all health factors to my therapist, including these not mentioned on my Health History Intake Form to avoid any complications. If I choose to experience these therapies during treatments, I understand the potential effects and after care recommendations. It has been explained to me that there is a possibility of discolorations that can occur from the release and clearing of stagnation and toxins from my body. I also understand that this reaction is not bruising, but due to cellular debris, pathogenic factors and toxins being drawn to the surface to be cleared away by my lymphatic and circulatory system. I further understand that the discolorations will dissipate from a few hours to as long as 2 weeks in some cases and in relation to my aftercare activities. I understand that the first time I experience Gua Sha; my body’s immune system can temporarily react to this release as it might with flu-like effects, water helps to dilute the intensity of the release. I agree to allow the Gua Sha Therapist to perform Gua Sha. I also agree that I have read, understand and will follow all the information provided and will not hold the practitioner/therapist responsible.

    I have provided all my known medical information. I acknowledge that gua sha therapy is not a substitute for medical diagnosis and treatment. I consent to receive treatment.

    By my electronic signature below, I agree to the treatment policy and client agreement above.

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