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Client Health Questionnaire


Please check all that currently apply:
Are you currently taking any medications?
Are you allergic or sensitive to:
Primary goal(s): (please check all that apply)

Informed Consent for Somatic Therapy Session

I understand that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease. Because massage must not be performed under certain circumstances, I have made the therapist aware of my existing medical conditions. It is my responsibility to keep the massage therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge.


If I experience any pain or discomfort during the session, I will immediately communicate it to the therapist so the treatment can be adjusted. If I have any questions about the therapy, I know that I am free to ask, and that the therapist will happily answer.


By submitting this form, I acknowledge that I have read a copy of the therapist’s policies; I understand them and agree to abide by them

Thank you for submitting!

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