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Full Chest/Upper Body Massage Intake

Personal Info
Contact Info
Emergency Contact
Doctor
Conditions
Neck
No PainTake me to the hospital
Highly AgreeHighly Disagree
Chest
Highly AgreeHighly Disagree
No PainWorst pain, feels like I'm going to collapse
Upper Back
Highly AgreeHighly Disagree
No PainI can't move, take me to the E.R.!

Acknowledgement and Consent for Massage

I understand that the massage therapist will assess my tissues, but does not diagnose illness, disease, or any other physical disorder. As such, the massage therapist does not prescribe or perform medical treatment, nor spinal manipulation. It has been made clear to me that massage does not substitute for medical examination or treatment. I understand my responsibility to report changes in my health and to give feedback during treatment so the practioner and I can work together as a team to optimize my experience. If I feel uncomfortable for any reason during the session, I am at my liberty to stop the treatment at any time.

I am happy to work at your comfort level of undressing. We can easily work together through clothing (except shoes and belts). Would you feel most comfortable receiving massage:
Ribs, diaphragm and pectoral massage treatment can include breast bone, underarms, the diaphragm, as well as the upper and lower chest immediately above and below the breast tissue. There may be contact with the breast tissue during this session: