Health History Form


Prior to your first appointment, please fill out the brief health history form and indicate your areas of concern or discomfort as applicable.



​The client-therapist relationship is one of mutual respect and agreements to help create clarity of intention.  Throughout the time the client and therapist work together, the client should feel free to express any thoughts, feelings, questions, or concerns that relate to the massage session.  With this in mind, the therapist asks for clients to respect the following policies.

Clients may seek massage therapy for relaxation, stress management, easing muscular tension, educational purposes, and for blood circulation and metabolism.  The massage therapist does not diagnose or treat any medical illness or physical disorder, but is responsible for working with the client to form a treatment plan suitable for his or her needs based on the above criteria.  The practitioner concerns only with the musculature of the body and does not perform adjustments nor prescribes medication. 

Massage therapy should never be used in place of medical care. As per the North Carolina Board of Massage & Bodywork Practice Act, the therapist will maintain all confidentiality of all clients' information except in the event the client agrees to disclosure in writing, or by court order.  The therapist will maintain client files for at least four years after sessions discontinue in a secure manner, and will subsequently destroy and dispose of these records.

Massages involve non-sexual touch, and should the client make advances toward the therapist or express sexual intent, the therapist has the right to terminate the massage session immediately.  The therapist is under a legal obligation to avoid relationships with cilents that could impair professional judgment or result in the client's exploitation.  The therapist must provide draping materials to cover the genital and gluteal areas of male and female clients, and the breast area of female clients.

The therapist shall not be held liable for any conditions that arise after the massage. Clients agree to consent to this and future massages the client may schedule, as per the therapist's informed consent form.  Consent may be withdrawn at any time by either party, and clients are encouraged to continuously communicate boundary requirements with the therapist.  The client agrees to state all information on the health history form accurately and completely, and will inform the therapist of any new conditions or changes in health.


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