New Client Health Intake Form

New Client Health Intake Form

Please fill out our required Health Intake Form 24 hrs prior to your session.
❁ 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 offer two types of sessions, and every journey starts with a Relaxational Massage. This session reduces stress, improves circulation, and allows your therapist to gently assess patterns of tension.

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 your session—to share your goals, comfort levels, and feedback via text in 2-3days. Together, we’ll build the foundation for safe, effective, and personalized care.

For ongoing concerns beyond Relaxational sessions, please go ahead complete the Customized Therapeutic Massage Intake Form to address specific problem areas so that therapist can guide you better in your wellness journey.

☺ Trust the process, celebrate small progress, and know we’re here to support you every step of the way. ☺
Having trouble submitting the form?
Please take a moment to double-check that all required fields (*) are filled out. Most submission issues happen when a field is accidentally left blank. (Error message wills pop-up with how many errors) 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.
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 am a traveler. Just need a general full-body relaxation, light tune-up of the body, I have no particular area needs to be addressed.- I am 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 totally customized for me after this initial session. (If that's the case, go ahead submit required online customized Therapeutic Health Intake Form as well so that your therapist can guide you better, if pain is severe, we can accommodate you with Customized Therapeutic session instead. Feel free to send a text for more help and don't pre-pay for your session in this case.)
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, 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. (Check Email 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.
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 Report part (Not the image part) *:
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 (I can help with Simple C-curvature. Please go for Customized Therapeutic session, not Relaxational session. 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 report part can be very helpful! (Not the image since I'm not trained to read the image)

Cancelof
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.*
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.

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 this process of Change/Cancel appointment easy 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 don't have an internet connection 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 screen will show you if you have incompleted section.
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New Client Health Intake Form

A friend sent you?

COVID Waiver

Cancel Policy

Client Arrival and Health Intake Form Policy