New Client Health Intake Form

New Client Health Intake Form

Please fill out our required Health Intake Form 24 hrs prior to your session.
To change language, please use the pull-down on the top right side corner.

❁ All Care Begins with Relaxational Massage ❁

Welcome to Aira Massage Wellness KY, and thank you for choosing us as part of your wellness journey!

We use this 2-in 1 form (for both Relaxational & Cutomized Therapeutic session) to build your customized care!
Your input is important!!

We offer two types of sessions, Relaxational Massage for general relaxation/new client assessment and Cutomized Therapeutic Massage for targeting specific part of area with pain/discomfort coming from injuries or specific conditions and every journey starts with a Relaxational Massage. This session reduces stress, improves circulation, and allows your therapist to gently assess patterns of tension with American style Swedish Massage.

We recommend a 60–90 minute full-body Relaxational Massage for your first visit, though you’re welcome to choose the duration that best fits your time and budget.

Open communication is key!! Please use this form—and during your session—to share your goals, comfort levels, and feel free to send your feedback via text in 2-3days. Together, we’ll build the foundation for safe, effective, and personalized care.

☺ Trust the process, celebrate small progresses, and know we’re here to support you every step of the way. ☺
Having trouble submitting the form?
When you skip required field (*) Error message wills pop-up on very top of the screen with number of errors. Make sure if specific secition is not applicable to you, then type "na" and proceed to next question.
Full Name*

First NameLast Name
Mobile Phone*
Email Address*
example@example.com
Birthday*

MonthDayYear
Date
What is your age group?*
If you are over 50-years old, please make sure to communicate you have low bone density condition, if you have this, please consult your doctor first, and get their instruction before coming to session.
What is your profession?*
This will help us to see how your daily-basis movement can affecting your muscles.
Any repetitive movement or task that affecting your muscular wellbeing during your work?*
Do you exercise?*
This will help us to see how your daily-basis movement can affecting your muscles.
What type of exercise mainly do you do?*
This will help us to see how your daily-basis movement can affecting your muscles.
What is your gender?*
Purpose of this question is to refer you out for certain treatment to other professionals if we can't provide it. For example, we'll not perform adductor strain (groin pain) treatment to male.
Have you ever had professional massage therapy before?*
What type of massage did you most benefitted from the prior professional massage therapy? *
This will help therapist to grasp your needs
Emergency Contact Full Name*

First NameLast Name
Emergency Contact Phone#*
Please enter a valid phone number.
Referred by/How did you hear about us?*
A friend sent you?

Let us know their name below
Name

First NameLast Name
What brought you here today？

I'm local resident who just randomly try relaxational purpose massage in a new places on a whim to tune up my body. I don't need regular-basis care.- I am local resident, and I'm up for regular basis Relaxational massage to maintain my good health condition & release accumulative muscle tensions (not the kind that is chronically tight) I have no particular area needs to be addressed.I am Geriatric generation, looking for gentle techniques to support circulation since my movement is significantly reduced daily basis.I'm in need of Sports massage & stretching before / between marathon training ( or Sports related).- My body holding patterns of pain (s) / discomforts / extreme muscle tightness that keeps coming back (chronic state), I need pain mitigation, relief with more targeted massage customized for me after this initial session.
Contraindications (No-go)For Massage &
Client -Therapist Safety Policy

At Aira Massage & Wellness, the safety and well-being of both our clients and therapists is a top priority. If you are experiencing any contagious or infectious conditions—such as those caused by fungal or viral infections—or if you’ve felt unwell within the past 3 days, and appointment sccheduled in 3 days, your session must be rescheduled.

We ask that you wait until you are fully symptom-free for at least one to two weeks after your fever subsided. Client is responsible to Change/Cancel Appointment from sent (4) Emails to do easy online "Change/Cancel appointment" button up to 24 hours prior to your session date)

Massage can temporarily lower body temperature and may interfere with your body’s natural healing process. Rest is essential—let your body do its work, and we’ll be here to support you once you’re fully recovered.

Please, don't skip this around, we don't want client show up with medical device or nuts & bolts in them or joint replaced and not get notified, etc. It is for your own safty!! Please let your therapist know on this form.
*** VERY IMPORTANT *** The conditions listed below is absolutely No-go for massage. Please check if anything applicable :
These listed are absolutely No-go for massage. Please check if anything applicable:*

FeverFluCOVID-19Sinus infectionCommon coldRecent vaccinations or injectionsChicken/Monkey PocksAny disease seen by Dermatologist such as Cystic acne, Fungal infection, viral infection on your skinHepatitis (Liver disease)TuberculosisKidney diseasePregnancy (especially first trimester)Bursitis (inflammation around joint fluid filled suck)Uncontrolled hypertension/Low blood pressureKnee Replacement - (We can't touch the area)Hip Replacement - (We can't touch the area)Uncontrolled (not seen by MD & no prescription) Heart diseaseUncontrolled (not seen by MD & no prescription) DiabetesSunburn (you got a red neck? No massage)Active cancer( I am not specialized in this type of massage, I can refer you out)Deep vein thrombosis (DVT)Mental health conditionsFractured boneOsteoporosis (fragile bone) or recently started to have lower value in density than usual, make sure communicate with your therapist with MD's report & instruction!!Skin lesions (open wounds), burns, or severe skin conditionsPoison IvySingles/cold sore or Fever blisterImpetigo - Sore around the mouth)Hematoma - Bruise with sorenessBed soresCellulitis - Inflammation of the cellPitting Edema - Swelling that staying indented when you press on skinPhlebitis -Inflammation in the vein)Excessive alcohol or substance intake habitScoliosis S-Curvature (more than one curvature on the spine)None of them applicable to me
Please check anything applicable below. Some conditions are workable if sufficient information was provided in advance. We may ask just a MRI written part of Report (Not the image part, I dont read image.) *:
Please check any applicable below. Some conditions are workable if information was provided. :*

Herniated disc (can work around it but not on it. Please upload screenshot of MRI report. (Consider Customized Therapeutic session after the initial session)Recent major surgery or trauma within 8 month.(Please upload screenshot of MRI report. If your MD is ok with massage, we can avoid the affected area and promote the blood circulation with gentler touch. Consider Customized Therapeutic session after the initial session)Any device installed in your body (!! Please!! upload screenshot of MRI report. We can do very gentle touch to promote blood circulation around it, not on it if your MD is ok with massage.)Any nuts bolts in your body - !! Please upload screenshot of MRI Report part (not the image).Varicose vein (can work around it but not on it)Recent illnesses or injuries - Please upload screenshot of MRI Report part. Consider Customized Therapeutic session after the initial session)Scoliosis with C-curvature - Please go for Customized Therapeutic session, not Relaxational session for this unless you just want general relaxational massage. Upload MRI Report part & Doctor's clarification what side (Left or Right ) of what part spines is tight /concaved (curvature details) before purchasing the session.)None of them applicable to me
- Screenshot of MRI written report part can be very helpful! Having the specific name of the muscles makes therapist understand situation quick. (Not the image part since I'm not trained to read the image)

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Please write anything additionally your therapist needs to know before the session:
(How did you get it / How long having it / What part of body is affected, Seen by Doctor? What kind of treatment received/receiving?)

We'll try best to provide the most appropriate type of session based on the health intake such as Post-Op situation.
Notes to your therapist, you can share your wellness goal here as well.
If you chose 30 - 45 minutes session, please choose which you need to be worked on*
If you chose 60 minutes and just wants to get massaged upper body or Lower extremities please choose from drop down menu. For example, if you like " I want my neck done longer" then choose Upper body focused*
Are you currently taking any medication?*

YesNo
Please list the medications you currently taking.*
Do you have any allergies or hypersensitivity for example nuts/particular type of oils, cream, lotion/latex/fragrance/essential oils?*

YesNo
Please list your allergies or hypersensitivities if you have.*
Chronic Pain? - Customized Therapeutic Massage requires additional information.

If it is not applicable, just put 'NA' to avoid errors.
Did you get your medical professional's diagnosis on your pain/discomfort?*

YesNo
What is the name of Diagnosis?:*
Upload your screenshot of MyChart Doctor notes, X-Ray/MRI written report part (not the image part) It allow massage therapist to get informed accurate information about your condition, especially help narrowing down affected muscles.

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Tell us how long the main area of the pain/discomfort is going on?*
Tell us what movement makes the pain worse? *
Any movement restriction on the main area of pain/discomfort?*
Tell us what is your wellness goal related this pain/discomfort?*
Cause of the pain/discomfort?

Pain caused by muscle overuse at workPain caused by muscle overuse doing sportsPain caused by bad body mechanicsPain caused by Motor vehicle accidentNumbness tingling due to muscle staying being too tightMuscle mass imbalance (one side over developed for some reason)Muscle imbalance (some muscle are weakened)Pain caused by diagnosed illnesses/conditions.Others (pls explain in below)
Please explain detail if you answered "Others" for Cause of the pain/Discomfort"*
Any secondary area that needed to be addressed once the main pain/discomfort was resolved? cause, area/side affected, duration of pain, etc.*
The Main symptom of your pain/discomfort
What is your main symptom of pain /discomfort specific to your session chosen?*

N/ A- I just want general Relaxational massageHeadachesNeck painShoulder pain -pain on the top of humerusShoulder pain - pain on the back of scapulaShoulder Pain - pain on between neck and edge of shoulderShoulder pain- pain under the arm pit (front part of scapula)Shoulder joint painShoulder joint replacedUpper back pain around the shoulder bladesWhiplash from the past auto accidentsSymptoms of TOS (Thoracic Outlet Syndrome)Carpal TunnelPain around Forearm & Elbow (Golfer’s or Tennis elbow)Lower back painHip painsciaticaHip Joint replacedFoot pain (Plantar fasciitis)somehow recurring ankle sprains (tear in ligament)Ankle sprain (tear on ligament)Ankle strain (Tear on Tendon or muscle)Can't receive massage face down position due to pregnancy but I can do side laying position.Can't lay in face up position due to pain but I can lay on side laying position.Just had a surgery but I need massage badNone of above (please explain more in anywhere you can type. )
The Main area of your pain/discomfort
Check anything applicable related to the main discomfort or pain for the session.*

N/A - I just want general Relaxational MassageI already uploaded MyChart MRI written report part (not the image) regarding my affected area where I want get treatedHead-Left sideHead -Right sideHead - around temple -Both sidesOccipital area where neck meet headNeck all aroundNeck and Top of the shoulderNeck -LeftNeck -RightAround Scapula -Left sideAround Scapula -Right sideOn the scapula - Left sideShoulder joint (Top of the humerus) LeftShoulder joint (Top of the humerus) -RightShoulder joint back side along the jointShoulder joint pain -front side along the jointShoulder range of motion-I can't raise my arms above shoulder both side at allShoulder range of motion-I can't raise my Left arm above shoulderShoulder range of motion-I can't raise my Right arm above shoulderShoulder range of motion-I can't raise my arm all the way touching the ears but can raise little above shoulder & feeling pain doing so.Arm -LeftArm -RightForearm -LeftForearm -RightWrist -LeftWrist -RightLower back-both sideLower back-both side but one side hurts moreLower back-LeftLower back -RightHips - Both sideHip - Both sides but one side hurts moreHip -Left pain from tightness overallHip -Left side pain & numbness, tingling sensationHip -RightHip -Right pain from tightness overallHip -Right side pain & numbness, tingling sensationLeg-LeftLeg -RightThigh-RightThigh -LeftKnee -LeftKnee -RIghtAnkle -LeftAnkle -RightFoot -LeftFoot -RightNumbness tingling pain on 1st 3 fingers (Carpal tunnel ) -LeftNumbness tingling pain on 1st 3 fingers(Carpal; tunnel) -RightNumbness tingling pain on last 2 fingers -LeftNumbness tingling pain on last 2 fingers -RightNumbness tingling pain down the arm & whole hand -Left (TOS)Numbness tingling pain down the arm & whole hand -Right (TOS)Numbness tingling pain on Hip down -LeftNumbness tingling pain on Hip down -Right
Are you currently receiving ongoing recovery care?*

N/ANot anymorePhysical TherapyAcupunctureChiropractic careBotox injectionSteroids injectionOthers
If you answered "Others" above, please tell us what other ongoing recovery care.*
Did your Dr. recommended massage therapy?
Timing of most painful/uncomfortable regarding your problem area (Not applicable? Just put 'NA')
What type of pain /discomfort are you experiencing?*
Please add anything related to your pain and discomfort such as type, most painful time, etc.*
Movement Restriction

Any chores you usually do became harder to do? *If you have any Joint Replaced, we are not doing the joint movement or massage right on that area unfortunately since it is out of our scope to treat, please consult your Dr. and Physical Therapist for further assistance for specific recovery care. What we can is to loosen up the surrounding area of muscles.
Is there any activities you cannot do due to the pain/discomfort or movement restriction?*
For your main pain/discomfort, did you get an Motor Vehicle Accident in the past?

*Please wait at least 72 hours for making massage appointment from the date of the incident* If you got in an accident and experiencing Whiplash effect, please explain below.
About the car accident, how long ago?
Check anything applicable for what you were doing right before & upon the motor incident impact.

I slammed onto Blake very hardI held onto the wheel very hardI was looking at the rear view mirror since I heard the noise from behind.I was looking at the passenger seat side mirror.I was the driver looking at passenger beside meI got hit from frontI got hit by rearI got hit by right sideI got hit by left sideI was on driver seatI was on passenger seatMy headrest was not thereI wore SeatbeltMultiple point of impactI hit my headI hit my kneeI got broken bone (Please explain what part in the section below)I was riding on motorcycle with full protectionI was riding motorcycle without protective gears
What kind of treatment you tried for treating the motor incident caused pain?

Physical TherapyChiropractic careMassageAcupunctureMagnet therapyOther (Please explain in below)
Anything to add?
Are you still receiving the care you mentioned above?

YesNo
Are you currently taking any medication for your discomfort or pain?

YesNo
Please tell us what type of medication you are taking for your discomfort or pain?
COVID Waiver

-Multiple Choices-
COVID 19 Questionnaire In the past 14 days have you experienced any of the following symptoms?*

Fever 101 degrees or higherUnexplained body achesCoughing/Sore ThroatUnusual fatigueNon allergy related runny noseTraveled outside of the countryShortness of breathLoss of taste and smellNone of the aboveI agree that I am providing accurate health information. I acknowledge the contagious nature of COVID 19 and that Aira Massage & Wellness KY, LLC has put in place preventative measures to reduce the spread. I understand I must wear a mask during service. I understand that my practitioner may wear gloves and a mask while performing services as recommended by the CDC.
Cancel Policy
Cancelling with less than a 24 hr notice is subject to a 100% of the service cost. We DO NOT accept texting or social media messaging for cancellations. Client is responsible to process their own Change/Cancel Appointment from provided Emails 24 hours prior to scheduled session.

Same-Day Booking Policy
Must book at least 3 hours in advance & Submit the Health Intake asap.
No refunds for missed or canceled same-day appointments—full charge applies.

We understand life happens and made easy this process of Change/Cancel appointment up to 24 hours prior to your session date.

Check your Confirmation E-mail or Reminder Emails, click the button "Change /Cancel Appointmet" at least 24 hr in advance or Leave a voice message by calling 502.373.1807 if you can't use Email due to Poweroutage.

If you need additional reminders, you can also see option buttons "Add to Google calendar"or "Add to iCal/Outlook calendar" so that you don't forget your session. We also send out Three reminder Emails & One Text reminder as well.
Client Arrival and Health Intake Form Policy
To ensure you receive the full benefit of your scheduled massage session and to respect the time of all clients:

Late Arrival: If you arrive late to your appointment, your session will still end at the originally scheduled time. This ensures that other clients are not delayed. Full payment for the session is still required.

Extremely Late Arrival: If you arrive more than 15 minutes late, it will be considered a missed appointment at the practitioner's discretion, and your session may be canceled without a refund.

Incomplete Health Intake Form: If you fail to complete the required health intake form prior to your appointment, the time spent filling it out will be deducted from your session time. Please make sure to fill out incomplted section if you have trouble submitting the form. The error will shown on the top of the screen if you have incompleted section.
By booking my appointment, I acknowledge and agree to these policies.
Before hit 'Submit'

If I don't see 'Thank You' landing page after hit the button "Submit" below, I understand that I need to check my form again by going top of the page where the errors show then complete each section until there is no longer error message then hit 'submit' button and confirm 'Thank You' landing page to complete the form submission.
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New Client Health Intake Form

A friend sent you?

Chronic Pain? - Customized Therapeutic Massage requires additional information.

The Main symptom of your pain/discomfort

Movement Restriction

For your main pain/discomfort, did you get an Motor Vehicle Accident in the past?

COVID Waiver

Cancel Policy

Client Arrival and Health Intake Form Policy