MASSAAH'G Bodywork & Coaching Experience

Complete Client Health History

Intake & Agreement Form - 2025

If under 18 years of age, enter guardian information below.

Guardian Date of Birth

Guardianship

Parent, Grandparent, Adopted Parents, etc.

Relationship to the Explorer (A)

Emergency Contact A Phone Number

Emergency Contact: B

Relationship to the Explorer (B)

Emergency Contact B Phone Number

Physical Activity Readiness Questionnaire (PAR-Q+) for MASSAAH'G Bodywork and Coaching

The Physical Activity Readiness Questionnaire (PAR-Q+) is designed to help us understand your current health status and identify any conditions that may require special attention, medical clearance, or modified treatment approaches. Your honest and complete answers ensure your safety and allow us to create the most effective, personalized healing experience for you.

Please answer YES or NO to each question. If you answer YES to any question, please provide detailed information in the space provided.

General Health Questions

1. Has your doctor ever said that you have a heart condition and that you should only participate in physical activity recommended by a doctor?

Yes

2. Do you feel pain in your chest when you participate in physical activity or experience chest pain at rest?

Yes

3. In the past month, have you had chest pain when you were not doing physical activity?

Yes

4. Do you lose your balance because of dizziness, or do you ever lose consciousness?

Yes

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity or by massage therapy?

Yes

6. Do you know of any other reason why you should not participate in physical activity or receive therapeutic bodywork?

Yes

Please Explain Your General Health

Cardiovascular and Respiratory Health

1. Do you have high blood pressure (hypertension)?

Yes

I don't Know

2. Do you have low blood pressure (hypotension)?

Yes

I Don't Know

3. Have you ever experienced a stroke, mini-stroke (TIA), or been diagnosed with cardiovascular disease?

Yes

4. Do you have any respiratory conditions such as asthma, COPD, emphysema, or chronic bronchitis?

Yes

5. Do you experience shortness of breath during normal daily activities or at rest?

Yes

Please Explain Your Cardiorespiratory Health

Musculoskeletal Conditions

1. Do you currently have any acute injuries, sprains, strains, or recent surgeries (within the last 6 months)?

Yes

If Yes, please specify location, type, and date:

2. Do you have chronic pain in any area of your body?

Yes

If Yes, please indicate location(s) and describe the pain:

3. Have you been diagnosed with arthritis (osteoarthritis, rheumatoid arthritis, or other types)?

Yes

If Yes, please specify type and the affected areas:

4. Do you have fibromyalgia or chronic fatigue syndrome?

Yes

If Yes, please provide details about your symptoms and management:

5. Have you had any joint replacements (knee, hip, shoulder, etc.)?

Yes

If Yes, please specify which joint(s) and when:

6. Do you have scoliosis, herniated discs, or other spinal conditions?

Yes

If Yes, please describe:

7. Do you experience numbness, tingling, or nerve pain in any part of your body?

Yes

If Yes, please indicate location(s) and frequency:

Metabolic and Endocrine Conditions

1. Do you have diabetes (Type 1 or Type 2)?

Yes - Type I

Yes - Type II

If Yes, is it well controlled? What is your average blood sugar level?

2. Do you have thyroid issues (hypothyroidism, hyperthyroidism, Hashimoto's, Graves' disease)?

Yes

If Yes, please specify condition and whether you are on medication:

3. Do you have any hormonal imbalances or conditions (PCOS, adrenal fatigue, menopause symptoms)?

Yes

If Yes, please here:

4. Are you currently pregnant or have you given birth within the last 6 months?

Yes

If so, how many weeks are you pregnant or post-partum; and have you received clearance from your healthcare provider for massage and fitness coaching?

1. Do you have varicose veins, deep vein thrombosis (DVT), or a history of blood clots?

Yes

If Yes, please specify and provide details:

2. Do you have lymphedema or have you had lymph nodes removed?

Yes

If Yes, please indicate location and whether you have received specialized lymphatic treatment:

3. Are you currently taking blood thinners or anticoagulant medications?

Yes

4. Do you bruise easily or have a bleeding disorder?

Yes

Skin Conditions and Sensitivities

1. Do you have any skin conditions (eczema, psoriasis, dermatitis, rashes, open wounds)?

Yes

2. Do you have any known allergies to oils, lotions, fragrances, or latex?

Yes

3. Are you sensitive to touch, pressure, or temperature?

Yes

Please list, explain, and specify all known skin allergies and pressure preferences:

Neurological Disorders:
Mental, Emotional, and Behavioral Health

1. Do you have a history of seizures or epilepsy?

Yes

2. Have you been diagnosed with multiple sclerosis, Parkinson's disease, or other neurological conditions?

Yes

3. Do you experience migraines or severe headaches?

Yes

4. Have you been diagnosed with depression, anxiety, PTSD, or other mental health conditions?

Yes

If yes to any of these questions: If Yes, when was your last seizure? Are you on medication? If Yes, how often? What are your triggers? Are you currently receiving treatment or taking medication?

Cancer and Autoimmune Questionnaire:

1. Have you ever been diagnosed with cancer?

Yes

2. Are you currently undergoing cancer treatment (chemotherapy, radiation, immunotherapy)?

Yes

3. Do you have an autoimmune condition (lupus, rheumatoid arthritis, Crohn's disease, celiac disease, etc.)?

Yes

If Yes, please specify type, treatment received, and date of completion or if you can provide details and clearance from your oncologist for MASSAAH'G:

1. Do you have irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), or other digestive disorders?

Yes

2. Do you have any abdominal hernias or recent abdominal surgeries?

Yes

1. Do you currently have a fever, cold, flu, or any contagious illness?

Yes

2. Do you have any active infections (bacterial, viral, fungal)?

Yes

If yes, please describe here:

Medication, Supplements, and Ergogenic Aids

1. Have you consumed alcohol or recreational substances within the last 24 hours?

Yes

If Yes, this may require rescheduling for your safety.

List your Prescribed medications, here:

List your Over the Counter (OTC) Medications, Drugs, and Supplements, here:

Lifestyle and Activity

1. How would you describe your current physical activity level? *

No ExerciseTraining Daily

1 Star - Sedentary; 2 Stars - 1-2x/week; 3 Stars - 3x/week; 4 stars 4x/week; 5 Stars = Athlete = Daily Exercise

2. Do you have any repetitive movements or physical demands in your work or daily life?

Yes

3. On average, how many hours per day do you sit?

4. How would you rate your current stress level?

Low

Moderate

High

Severe

5. How many hours of sleep do you typically get per night?

Less than 5 hours

5 to 6 hours

7 to 8 hours

8 hours or more

6. How would you rate your sleep quality? *

PoorExcellent

Please list your favorite foods, meals, and snacks.

Acknowledgment and Consent

I certify that I have read and answered all questions truthfully and to the best of my knowledge. I understand that it is my responsibility to inform Alyssa Miller-Nelson of any changes to my health status, medications, and physical condition before each session. I understand that if I answer YES to one or more questions, I may be required to obtain medical clearance from my healthcare provider before services can be provided; determined during our recorded zoom consultation call.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Please Sign here

Clear