0438 520 219 | 3/373 Glen Osmond Road, Glen Osmond, SA 5064 myintrinsicmind@gmail.com

Thai Yoga Massage Health Questionnaire

Please fill out the Thai Yoga Massage Health Questionnaire and Consent.

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.

**We aim to get back to you within 24 hours**

    Have you had a Thai Yoga Massage before?*

    If yes, please tell us about your experience

    Please indicate if you have any of the conditions listed below

    Coagulation & Platelets

    Cardiovascular Disease

    Joint Problems

    Soft tissue contraindication

    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*



    I hereby consent to this massage*

    3/373 Glen Osmond Road,
    Glen Osmond, SA 5064

     

    Jen 0406 939 090
    Leisa 0438 520 219

    myintrinsicmind@gmail.com

    Skype: intrinsic_mind