Caladrius Bodywork Book a Session

Before your first visit

Health information

This is the form you would otherwise fill out at the studio. It takes about five minutes. Only your name and the consent at the end are required — answer the rest as fully as you like, and skip anything you would rather talk through in person.

Your answers go straight into Elizabeth's private records and nowhere else. They are not emailed and are not visible to anyone but her. Details are on the privacy page.

About you

Helps match this form to your booking.

Insurance

Most clients skip this section. It only matters if a claim is involved.

Is this massage medically necessary — for a condition, injury, or surgery?
Do you have a physician referral or prescription?
Are you seeking insurance reimbursement?
Type of coverage, if any
Massage and bodywork
Have you had professional massage or bodywork before?
Pressure you prefer

Stress, pain, stiffness, numbness or tingling, swelling — whatever is going on.

Do these get in the way of daily life — sleep, exercise, work, childcare?
Are you pregnant?
Do you wear contacts?
Dentures?
A hairpiece?
Health history
Do you currently have any of these? Please answer honestly — massage may not be advisable with them, and Elizabeth would rather know before you arrive.

Unsure about one? Leave it and ask at the studio.

Conditions you have now or have had. Tick current, past, or both, and add detail if it helps.

Skip anything that does not apply — most people tick only a few.

Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch or pressure
High or low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson’s, chronic pain)
Epilepsy, seizures
Headaches, migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn’s, IBS)
Gas, bloating, constipation
Kidney disease or infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine or disc
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine or thyroid conditions
Depression, anxiety
Memory loss, confusion, easily overwhelmed
Consent for care (required)

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware.

I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

Understanding all of this, I give my consent to receive care.

Signed electronically; the date and time are recorded when you submit.

Nothing is saved until you press the button.