New Client Health Intake Form

New Client Health Intake Form

Please fill out our required Health Intake Form 24 hrs prior to your session.
❁Thank you for choosing us as part of your wellness journey! ❁

Welcome to Aira Massage Wellness KY, LLC.

We use this 3-in 1 form for Hot Stone Oil Massage, Relaxational Massage & Cutomized Therapeutic Massage session to build your customized care!
Your input is important!!

⚠️ Please do not skip the Contraindications section.
Be sure to describe your health conditions in your own words—especially if you have any medical conditions, implants, or are currently under a medical provider’s care.

Open communication is key!! Together, we’ll build the foundation for safe, effective, and personalized care.

☺ When it comes to pain management,it is important to trust the process, celebrate small progresses, and know we’re here to support you every step of the way. ☺

Regular sessions build cumulative benefits over time and enhance the effectiveness of massage—making it a worthwhile investment in your wellness.
Having trouble submitting the form?
If a required (*) field is missed, an error message will appear at the top of the screen showing the number of errors. If a section does not apply to you, please type “NA” and proceed.
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.
What brought you here today?*
Wellness Goal?*
Any medications currently taking?*
Please list your medications*
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?*
First time with Professional massage session? You will undress to your own comfort level and get between the sheets, you will be covered whole time and only exposed where you get massaged. Appropriate draping will be always done for you. We'll use lotion or oil during massage. Feel free to wipe off after session with provided wet tissue.
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
Please check on most applicable to you today.

I'm local resident who just want randomly trying a relaxational Massage (American-Style Swedish Massage) or Hot Stone Oil Massage in a new places on a whim to tune up my body. I don't need regular-basis care.I am visiting Bardstown on vacation, just seeking general relaxational massage after long walk around.- I am local resident, and I'm up for regular basis Relaxational massage to maintain my good health condition & release minor 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 (European Swedish Massage) 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) with Customized Therapeutic Massage session.- My body holding patterns of pain (s) / discomforts / extreme muscle tightness that keeps coming back (chronic state) due to new injuries, old injuries, on-going illness, post-surgery situation, I need pain mitigation, relief with more targeted massage customized for me after this initial session.
Contraindication (Absolute)

If you feel unwell within 3 days of your session, please reschedule or cancel your appointment. If symptoms are still lingering, kindly wait until you are fully recovered before booking. We are taking extra care to prevent spreading infectious illness.

If you have any implanted medical devices or artificial parts in your body, please inform your therapist in advance.

At Aira Massage & Wellness KY, we take safety very seriously—for both clients and therapist. Safety is our top priority at all times.
These listed are absolutely 100% No-go for massage.*

FeverFluCOVID-19Sinus infectionAny virus caused illnessCommon coldRecent vaccinations or injectionsChicken/Monkey PocksShingleCystic acneViral skin infectionFungal infectionAny conditions seen by DermatologistHepatitis (Liver disease)Tuberculosis (infectious lung illness)Kidney diseasePregnancy (especially first trimester)Bursitis (inflammation around joint fluid filled suck)Uncontrolled hypertension/Low blood pressureUncontrolled Heart diseaseUncontrolled DiabetesSunburnActive cancerDeep vein thrombosis (DVT)Severe Mental health conditionsFractured bonesOsteoporosis (fragile bone)Skin lesions (open wounds)Burns, or severe skin conditionsPoison IvyCold sore or Fever blisterImpetigo - Sore around the mouth)Epstein BarrsHematoma - Bruise with sorenessBed soresCellulitis ( Inflammation of the cell)Pitting Edema - Swelling that staying indented when you press on skinPhlebitis -Inflammation in the vein)Excessive alcohol or substance intake habitNone of them applicable to me.Drunk after burbon tour
Contraindications (Local)

We will do our best to provide appropriate care based on the information in your health intake (such as post-operative conditions). A local contraindication means we may work on surrounding tissues while avoiding the affected area.
Please check any applicable below.*

Any Replaced part in the body Artificial/Non-artificial.Hip joint replacementShoulder joint replacementNuts & Bolts in jointPacemaker or similar artificial device in your body (explain below)Recent major surgery or trauma within 8 month.Herniated discVaricose vein (can work around it but not on it)Lumber spine Spinal fusion onRecent illnesses or injuriesNeck Spinal fusionScoliosis with C-curvatureScoliosis S-Curvature (more than one curvature on the spine. We can only provide general relaxational massage)I have some conditions checked and my physician recommended to get massage.Still seen by doctorStill going physical therapyNone of them applicable to meNone of them applicable but I have something I need to explain.
- Screenshot of MRI written report part can be very helpful! Saves time.

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Describe about any replaced body parts.*
Describe any past surgery. (or anything you need to explain)*
Describe if your physician recommended massage*
Hot Stone Oil Massage Contraindications

-Multiple choices - Please check below regardless you purchased hot stone or not. Please consult your physician if you have anything applicable below before booking session. We'll follow your physician's (MD) instruction.
Please check any applicable below. :*

Pregnant over 4 monthsProne to Blood clots, Varicose veinsCancer, chemo or radiation treatmentAny nuts & bolts in your bodyVaricose vein (can work around it but not on it)Heart problemsHigh blood pressureTaking meds that have side effects to heartPeripheral vascular disorderHIV, AIDSDepressed immune system, Nerve trauma, NeuropathyEpstein BarrLupusMononucleosisOpen wounds, or sores,Inflamed skin conditionsDiabetesBruise easilyRecent surgeryHeat sensitivityFeverHaving tendency of making sudden movement during the sessionNone of them applicable to me
Notes to your therapist
If you chose 30 - 45 minutes session, please choose which you need to be worked on*
If you chose 60 minutes Relaxational Massage but don't wish to have full body massage, select Upper body or Lower extremities. For example, if you like " I want my neck done longer" then choose Upper body focused*
Do you have any allergies or hypersensitivity for example nuts/particular type of oils, cream, wax, lotion/latex/fragrance/essential oils?*

YesNo
Please list your allergies or hypersensitivities if you have.*
Need targeted relief for Chronic Pain/tightness? - 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?*
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 didn't choose Customized Therapeutic Massage session. Just want general Relaxational massageHeadaches (Neck & Head)Neck pain (Neck & top part of shoulder)Shoulder Pain - Pain on between edge of shoulder and towards neckShoulder pain -Pain on the top of humerusShoulder pain - Pain on the back of scapulaShoulder pain- pain under the arm pit (front part of scapula)Shoulder joint painShoulder joint replacedUpper back pain between the shoulder blades and spineWhiplash from the past auto accidentsSymptoms of TOS (Thoracic Outlet Syndrome)Carpal TunnelPain around Forearm & Elbow- Golfer’s elbowPain around Forearm & Elbow (Hairy side) -Tennis elbowLower 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 or face down.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 didn't choose Customized Therapeutic Massage session. 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?
We are not intended to ask this to cover insurance or take HSA card. We just need to know simply if Dr. recommended or not.
Timing of most painful/uncomfortable regarding your problem area (Not applicable? Just put 'NA')
What type of pain /discomfort are you experiencing in when is the worst?*
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. Replaced part's like hip or knee, life of part is commonly last about 10 years or so if it is cared properly, and highly recommended to keep moving that part based on PT instruction instead of resting all time do nothing which is pretty hard in reality with pain. What we can help is to loosen up the surrounding area of muscles. Regular basis massage can help prevent the joint damage, injuries in the future, well worth the investment!!
Is there any activities you cannot do due to the pain/discomfort or movement restriction?*
Is your main pain/discomfort related to an Motor Vehicle Accident in the past or recent one?

*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 4 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" 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.
Agreement on policies

By booking my appointment, I acknowledge and agree to these policies.
Before hit 'Submit' button

If I don't see landing page with 'Thank You' message after hit the button "Submit" below, I understand that I need to scroll up to the top page again & check the number of errors shown.
Signature
Should be Empty:

New Client Health Intake Form

A friend sent you?

Hot Stone Oil Massage Contraindications

Need targeted relief for Chronic Pain/tightness? - Customized Therapeutic Massage requires additional information.

The Main symptom of your pain/discomfort

Movement Restriction

Is your main pain/discomfort related to an Motor Vehicle Accident in the past or recent one?

COVID Waiver

Cancel Policy

Client Arrival and Health Intake Form Policy