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Bodywork Intake Form

Nervous System Tone Massage is a collaborative process. This information helps create a session that supports your body with clarity and intention.

Bodywork Intake Form

These answers guide our bodywork session.

Date

MM slash DD slash YYYY

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

How old are you?(Required)

How much do you weigh?(Required)

How tall are you?(Required)

Have you had any joint replacements?(Required)

No

Yes (if yes, please specify location and year)

Year and location of joint replacement:

Do you currently have or have a history of any of the following?(Required)

High blood pressure

Currently on blood thinners

Recent surgery (past 12 months)

Disc injury or spinal condition

Chronic headaches or migraines

Neuropathy or nerve pain

None of the above

Please list any injuries, current pain, or physical limitations. If none say none:(Required)

What is the primary reason for today's massage?(Required)

Areas to Avoid:

Head/Neck

Shoulders

Upper Back

Mid Back

Low Back

Glutes/Hips

Legs

Feet

Arms

Areas to Focus On:(Required)

Head/Neck

Shoulders

Upper Back

Mid Back

Low Back

Glutes/Hips

Legs

Feet

Arms

Full Body

Preferred Pressure Level:(Required)

Light

Moderate

Moderate to Firm

Pressure will always be adjusted based on tissue response and comfort. I am currently not offering deep tissue or aggressive pressure massage.

Terms and Conditions(Required)

Approach to Care
This practice provides deep myofascial-informed therapeutic massage. Sessions incorporate sustained pressure and controlled movement to address muscle and connective tissue. Techniques are therapeutic in nature and may involve focused work in areas of tension or restriction.

Medical Clearance
By agreeing, I confirm that I have disclosed all relevant health conditions, injuries, surgeries, and medications. I affirm that I have received medical clearance from my physician or healthcare provider to receive massage therapy if I have any medical condition that may be affected by bodywork, including but not limited to high blood pressure, cardiovascular conditions, recent surgery, joint replacements, or use of blood thinners.

Client Responsibility
I understand that it is my responsibility to communicate any discomfort, pain, or changes in my condition during the session. I acknowledge that results vary and that no guarantees have been made regarding outcomes.

Liability Acknowledgment
I understand that massage therapy is not a substitute for medical diagnosis or treatment. I voluntarily assume all responsibility for my participation in massage therapy services and release Fever and its practitioners from liability for any injury or adverse reaction that may occur as a result of treatment, except in cases of gross negligence.

Consent
I consent to receive massage therapy under the terms stated above.

I agree to the terms and conditions.

Signature (Type Full Legal Name)(Required)

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Location
1154 Wealthy Street SE
Grand Rapids, MI 49506
Phone Number
(616) 805-3603

FeverLogo_YCS_2023

1154 Wealthy Street SE
Grand Rapids, MI 49506
(616) 805-3603

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