Date of Birth

Have you had a Thai Yoga Massage before?*

YesNo

If yes, please tell us about your experience

Please indicate if you have any of the conditions listed below

Allergies and AsthmaActive infectious disease (ex fever, cough etc)CancerCervical Spine ProblemsHerniaPregnancyRheumatoid ArthritisRecent Surgery

Coagulation & Platelets

HemophiliaAnticoagulant therapy - Coumadin, Warfarin or HeparinOther platelets or coagulation

Cardiovascular Disease

Brain or aortic aneurysmsHeart DiseaseHigh Blood PressureStrokeDeep Vein Thrombosis

Joint Problems

FracturesPrevious Dislocations

Soft tissue contraindication

Open wounds and cutsSkin Disease

Other, Please Describe

Do you hold any TENSION in your body, if so where?

Do you have any NUMBNESS in your body, if so where?

Do you have any MOVEMENT RESTRICTIONS for us to be made aware of, if so where?

Do you have any CRAMPING in your body, if so where?

Do you have any PAIN in your body, if so where?

Do you have any additional comments that you would like to inform your Thai Yoga Massage Practitioner prior to your appointment?

Consent for Thai Yoga Massage

I understand that the purpose of a Thai Yoga Massage is for relaxation and it is not meant to diagnose or treat any illness, disease or any other physical or mental disorder, injury or condition. I have informed my Thai Yoga Massage practitioner about my state of health and I have transmitted any recommendations and restrictions on the part of my medical doctor or therapist insofar as Thai Yoga massage is concerned.

I have answered all the questions truthfully and to the best of my ability*

YesNo

I hereby consent to this massage*

YesNo