SIMPLY THERAPEUTIC MASSAGE
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book now
services & rates
our team
gift a massage
faq & policies
intake forms
login
615-487-1585
2000 glen echo Rd.
suite 100
Nashville, TN 37215
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
bone spurs
cancer
chronic pain
depression/anxiety
diabetes
dislocated clavicle/shoulder
epilepsy
headaches
heart condition
high/low blood pressure
joint replacement
lymph nodes removed
plantar fasciitis/warts
pregnancy or nursing *COMPLETE PRENATAL INTAKE BELOW
sensitive to oils/lotions/scents
skin condition
swelling legs/hands/feet
toe fungus/athletes foot
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 massage
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 ever had a prenatal massage before?
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Any risk factors to be aware of?
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Are you experiencing any areas of discomfort?
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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
high risk pregnancy*
Other, please list:
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Simply Therapeutic Massage client/therapist prenatal massage agreement:
I have completed this health form to the best of my knowledge. I understand that Bodywork is a health aid and does not take the place of a physician's care.
If I am currently having or if I develop complications, I will discuss the condition with my massage therapist.
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
Simply Stretch Flow
intake form
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Indicates required field
Name
*
Phone Number
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Email
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Preferred contact method
*
Text
Email
Date of birth
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Pronouns
*
Right or left handed?
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Right
Left
Occupation
*
Emergency contact name and #
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Major surgeries or injuries:
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Do you have an experience with yoga/meditation?
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What are your goals? What would you like out of your session?
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Describe your job, daily life, stress level, regular repetitive movements, etc.
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Anything else I should know to best make your time suited for you?
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Consent and agreement:
If at any time during class, you feel discomfort, gently come out of the posture and notify your instructor. You may rest at any time during class. It is important in yoga that you listen to your body and respect its limits. I understand that yoga is not a substitute for medical treatment or diagnosis. I recognize it is my responsibility to notify my teacher of any serious illness or injury. I will not perform any postures to the extent of strain or pain. I understand and accept that neither the instructor, nor hosting facility, is liable for any injury, or damages to person, resulting from the taking of the class.
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 agree that I have read, understand, and agree to comply with all studio policies.
I AGREE
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I AGREE
Submit
book now
services & rates
our team
gift a massage
faq & policies
intake forms
login