SIMPLY THERAPEUTIC MASSAGE
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book now
services & rates
our team
gift a massage
faq & policies
forms & login
615-487-1585
2000 glen echo Rd.
suite 100
Nashville, TN 37215
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Simply Therapeutic Massage
new client intake form
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Indicates required field
Name
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Phone Number
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Email
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Date of birth
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Pronouns
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Preferred contact method
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Text
Email
Right or left handed?
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Right
Left
Occupation
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Do you exercise? If yes, what do you do?
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Emergency contact name and #
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When was your last massage?
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How did you hear about us?
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What do you want out of your massage today?
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Any areas you would like to focus on?
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Any areas you would like to avoid?
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Current medications:
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Major surgeries or injuries:
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Are any of these conditions currently or have affected your health?
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allergies
arthritis/rheumatism
asthma/breathing problems
bone spurs
cancer
chronic pain
depression/anxiety
diabetes
dislocated clavicle/shoulder
epilepsy/seizures
headaches
heart condition
high/low blood pressure
joint replacement
lymph nodes removed
plantar fasciitis/warts
PMS/PMDD/menopause
pregnant, postpartum, or nursing *If YES, complete Prenatal/Postpartum intake below
sensitive to oils/lotions/scents
skin condition
swelling legs/hands/feet
toe fungus/athletes foot
survivor of abuse/trauma *we will not ask details. Please let us know if there is anything specific we can or cannot do to make you feel comfortable and safe. All emotions are welcome at STM and will be honored.
Other, please list:
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Simply Therapeutic Massage client/therapist agreement:
I understand that massage therapy is non-diagnostic and not a replacement for care by a licensed physician. If I experience any pain/discomfort, I will immediately inform my therapist so pressure/methods can be adjusted to my comfort level. I understand massage should not be performed under certain circumstances therefore I agree to notify the studio of any changes in my medical information I have provided.
Simply Therapeutic Massage policies agreement
: STM has provided me with their policies and I understand that it is my responsibility to read these before my appointment. I have read, understand, and agree to comply with all studio policies.
I AGREE
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I AGREE
Submit
Prenatal/Postpartum intake form
Name
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Are you
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pregnant
postpartum
nursing
Expected due date
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How far along are you?
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Have you had a C-section? If YES, has it been 6 weeks?
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Is this your first pregnancy?
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Is this a high risk pregnancy?
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Any risk factors to be aware of?
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Have you experienced a prenatal/postpartum massage before?
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Are you experiencing any areas of discomfort?
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Are you experiencing or have experienced any of the following:
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allergies
asthma/breathing problems
birth trauma
bladder infection
blood clots of phlebitis
depression/anxiety/stress
digestive problems
dizziness
emphysema
gestational diabetes
fibromyalgia
headaches/migraines
heart condition
high blood pressure
implants
inflammation
leg cramps
miscarriage
poor circulation
preeclampsia (toxemia)
preterm labor
problems with placenta
skin condition
swelling hands/legs/feet
uterine bleeding
twins or more
Other, please list:
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Simply Therapeutic Massage client/therapist prenatal/postpartum massage agreement:
I understand that massage therapy is non-diagnostic and not a replacement for care by a licensed physician. If I experience any pain/discomfort, I will immediately inform my therapist so pressure/methods can be adjusted to my comfort level. I understand massage should not be performed under certain circumstances therefore I agree to notify the studio of any changes in my medical information I have provided.
Submit
Lymphatic Drainage
intake form
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Indicates required field
Name
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Phone Number
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What is the reason you are seeking lymphatic drainage?
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Have you ever received lymphatic drainage?
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yes
no
I don't know
Have you been cleared by your doctor?
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Do you have any position restrictions?
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What treatments/surgeries have you undergone (if any) and when?
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Are any of these conditions currently or have affected your health?
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Bruising
Cancer or cancer treatment
Enlarged lymph nodes
Lymph nodes removed
Pain
Swelling
Other, please list:
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Anything else you would like your therapist to know before you come in?
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Submit
book now
services & rates
our team
gift a massage
faq & policies
forms & login