SIMPLY THERAPEUTIC MASSAGE
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now hiring!
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lymph intake form
prenatal intake form
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book now
services & rates
our team
now hiring!
gift a massage
faq & policies
our friends
intake form
lymph intake form
prenatal intake form
login
615-487-1585
2000 glen echo Rd.
suite 100
Nashville, TN 37215
If you are new to STM please complete your intake form before your appointment. Thank you!
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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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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
chronic pain
depression/anxiety
diabetes
dislocated clavicle/shoulder
epilepsy
headaches
heart condition
high/low blood pressure
joint replacement
lymph nodes removed
pregnancy or nursing *COMPLETE PRENATAL INTAKE BELOW
sensitive to oils/lotions/scents
skin condition
swelling legs/hands/feet
intracranial/dural pressure
Other, please list:
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Simply Therapeutic Massage client/therapist agreement:
I understand that massage therapy is therapeutic, but it is non-diagnostic and not a replacement for care by a licensed physician. If I experience any pain or discomfort, I will immediately inform my therapist so pressure/methods can be adjusted to my comfort level. Because massage should not be performed under certain circumstances, I agree to notify the studio in writing of any changes in medical information I have provided today.
Simply Therapeutic Massage policies agreement
: I agree that Simply Therapeutic Massage has provided me with their policies and I understand that it is my responsibility to read these policies before receiving any bodywork. I agree that I have read, understand, and agree to comply with all studio policies and I consent to be legally bound by all studio policies.
I AGREE
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I AGREE
Submit
PRENATAL INTAKE FORM
Name
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Are you pregnant or nursing?
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How far along are you?
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Expected due date
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Is this your first pregnancy?
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Have you experienced a prenatal massage before?
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Are you experiencing any areas of discomfort?
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Any risk factors to be aware of?
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Are you experiencing any of the following:
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bladder infection
blood clots of phlebitis
gestational diabetes
high blood pressure
leg cramps
miscarriage
preeclampsia (toxemia)
preterm labor
problems with placenta
swollen hands and/or feet
uterine bleeding
twins or more
Other, please list:
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I AGREE
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I AGREE
Submit
If you are booking lymphatic drainage please complete:
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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
now hiring!
gift a massage
faq & policies
our friends
intake form
lymph intake form
prenatal intake form
login