New Client Health Intake Form

New Client Health Intake Form

Submission due : 24 hrs prior to your session. Failing can be subjected to reschedule per Aira Massage & Wellness KY's policies.
Welcome to Aira Massage & Wellness KY

Exciting updates are coming to Aira Massage & Wellness KY!

The wonderful owners of Belleza La Pelle have kindly offered to extend their support by allowing us to utilize their online booking system, receptionist, payment processing, and gift card services. We are working hard behind the scenes to integrate these processes and train the new receptionist, with a goal to have everything ready by early to mid-November.

At the same time, I am preparing to introduce a new service: Brazilian Lymphatic Drainage Sculpting for ladies!

As with any system transition, there may be a few minor hiccups along the way.
I will do my best to resolve any issues quickly, and I truly appreciate your patience and continued support.

Belleza Reception line

📞(502) 849 -4848
This number will be available after some time in November.

Direct line to Naomi
📞(502) 373-1807

(📞(833) 508-2027 number will be discontinued after some time in November)

When you don't see availability while you have severe pain that pause your daily activity

like having bad headache and need it resolved so that you can take care your kids for example), we'll try best to accomodate your session if possible. Text 502-373-1807.
To avoid errors

If some question doesn’t apply to you, enter “N/A” and complete the submission.
Full Name

First NameLast Name
Mobile Phone
Format: (000) 000-0000.
Email Address
example@example.com
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.
Do you have Low Bone density?
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.
If you answer "Others" for profession or how is your main movement routine, feel free to write below.
What brought you here today? Wellness goal? (-If you have usual place to go but decided to come to us this time, tell us the reason so that we can understand your particular needs.)
Please list your current medications
If you are on blood thinning medication, we are not able to apply deep pressure. Please talk to your physician & approval if that's the case. and choose Customized Therapeutic Massage session instead of Relaxational massage. This is not negotiable.
Pressure preference
This will help us to see how your daily-basis movement can affecting your muscles.
• Write any specific Pressure preference
• Any area must not touched? Why?
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. Refer you out for other professional.
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.Format: (000) 000-0000.
A friend sent you?

Let us know their name below
Referred by/How did you hear about us?
Name

First NameLast Name
Please check applicable to you today.
⚠️ Absolute Contraindications (NO-GO for Massage) ⚠️

Please reschedule your session.
Check anything applicable below.
⚠️ Local Contraindications ⚠️

-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.
- Screenshot of MRI written report part can be very helpful! Saves time.

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Describe about any replaced body parts. Where, Which side.
Describe any past surgeries & how long ago. (or anything you need to explain)
Describe if your physician recommended massage and why
⚠️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.
Interested in hot stone?
Please check any applicable below. :
Anything forgot to say? Notes to your therapist
⚠️Lymphatic Drainage Contraindications⚠️

-Multiple choices - Please check below regardless you purchased Lymphatic Drainage 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. :
Are you interested in Brazilian Lymphatic Drainage Sculpting?
For 💜Relaxational Massage session It designed to cover Full body. If you prefer partial treatment, Please choose below.
Allergies

Do you have any allergies or hypersensitivity for example nuts/particular type of oils, cream, wax, lotion/latex/fragrance/essential oils?
Please list your allergies or hypersensitivities if you have.
If it is not applicable, just put 'NA' to avoid errors.
Did you get your medical professional's diagnosis on your pain/discomfort?
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 or daily activity restriction on the main area of pain/discomfort?
Cause of the pain/discomfort?
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.
Your main area of discomfort
What is your main symptom of pain /discomfort specific to your session chosen?
Main area of discomfort

Affected side or sides
Check anything applicable related to the main discomfort or pain for the session.
Current 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.
Are you currently receiving ongoing recovery care?
If you answered "Others" above, please tell us what other ongoing recovery care.
Timing of most painful/uncomfortable regarding your main problematic area?
Please explain below.
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.
What kind of treatment you tried for treating the motor incident caused pain?
Anything to add?
Are you still receiving the care you mentioned above?
Are you currently taking any medication for your discomfort or pain?
Please tell us what type of medication you are taking for your discomfort or pain?
Aira Massage & Wellness KY Policies
COVID Waiver

-Multiple Choices-
COVID 19 Questionnaire In the past 14 days have you experienced any of the following symptoms?
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.
Practice Policies & Right to Refuse Service Professional Boundaries
This is a professional, therapeutic massage and bodywork practice. Any illicit, aggressive, or inappropriate remarks, behavior, or sexual innuendo will result in the immediate termination of the session, and the client will be responsible for full payment. Mutual Respect: We believe in a therapeutic environment built on mutual respect. We maintain zero tolerance for discriminatory behavior, harassment, or microaggressions of any kind toward our staff.

Right to Refuse Service: To protect the safety, well-being, and professional boundaries of our practitioners, this business reserves the absolute right to refuse service, cancel appointments, or terminate the client relationship at any time, at our sole discretion.
Client Arrival & 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
Before hit 'Submit' button
Should be Empty:

New Client Health Intake Form

A friend sent you?

⚠️ Absolute Contraindications (NO-GO for Massage) ⚠️

⚠️ Local Contraindications ⚠️

⚠️Hot Stone Oil Massage Contraindications⚠️

⚠️Lymphatic Drainage Contraindications⚠️

For 💜Relaxational Massage session It designed to cover Full body. If you prefer partial treatment, Please choose below.

Allergies

Did you get your medical professional's diagnosis on your pain/discomfort?

Your main area of discomfort

Main area of discomfort

Current recovery care?

Timing of most painful/uncomfortable regarding your main problematic area?

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

Aira Massage & Wellness KY Policies

COVID Waiver

Cancel Policy

Practice Policies & Right to Refuse Service Professional Boundaries

Client Arrival & Health Intake Form Policy