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Health History & Consent Prior to Thai Yoga Massage

Do you have any current medical conditions or concerns?
Yes
No
Have you had any recent injuries, surgeries, or illnesses?
Yes
No
Are you pregnant or trying to conceive?
Yes
No
Do you have any chronic pain or tension areas?
Yes
No
Do you have any allergies (e.g. oils, lotions, etc)?
Yes
No
Do you experience any of the following? Check all that apply.
Do you have any cardiovascular conditions?? (e.g. heart disease, blood clots, varicose veins, etc)
Yes
No
Are you currently taking any medications?
Yes
No
Have you ever experienced dizziness, fainting or seizures?
Yes
No
Where on your body do you prefer the focus to be on for this Thai Massage session?

Consent and Acknowledgement

  • I understand that Thai Yoga Massage is not suitable for medical care, diagnosis or treatment

  • I have disclosed all relevant medical information to the best of my knowledge

  • I will inform my therapist of any changes to my health in future sessions

  • I consent to receiving Thai Yoga Massage and understand that the therapist will use techniques involving stretching, compression and joint mobilization

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