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Healing Beyond Pain

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"IF YOU DON'T GET RELIEF, YOU DON'T PAY"

Medical History

First name

Last name

Phone

Reason for Today’s Session (Please describe your main concern, discomfort, or goal for today’s session)*

Medical History

Please check all that apply and provide details where relevant.

Chronic pain

Acute injury

Arthritis

Fibromyalgia

Migraines / Headaches

TMJ / Jaw pain

Sciatica

Herniated or bulging disc

Spinal surgery

Joint replacement

Tendonitis / Bursitis

Neuropathy

Autoimmune condition

Cancer (current or past)

Osteoporosis / Osteopenia

Blood clots / DVT

Heart condition

High blood pressure

Diabetes

Seizures

Stroke

Respiratory condition

Skin condition

Recent illness or infection

Pregnancy

Other

Please explain any conditions checked above:

Medications & Supplements

List any surgeries, accidents, or significant injuries (include dates if possible)

Pain & Sensitivity Awareness

Please check any areas that are painful, sensitive, or should be avoided:

Neck

Shoulders

Upper back

Lower back

Hips

Glutes

Legs

Feet

Arms

Hands

Abdomen

Chest

Head / Face

Pain Level Today (0–10)*

Pressure Preference:*

Light

Medium

Firm

Therapeutic / Deep

Sensory & Comfort Preferences (Optional but Encouraged)

This helps us tailor the session to your nervous system.

Quiet session (minimal talking)

Guided explanation during treatment

Music preferred

Silence preferred

Extra warmth

Extra grounding / slower pace

Trauma-informed approach requested

Anything else that helps you feel safe and comfortable?

Consent & Acknowledgment

Please read and sign below.

I understand that massage therapy and bodywork are not a substitute for medical diagnosis or treatment.
I have disclosed all relevant health information to the best of my knowledge.
I understand I may stop or request changes to the session at any time.
I consent to receive therapeutic bodywork from Alfa Therapy LLC.

Signature*

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Parents Signature if under 18*

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Date*

Month

Day

Year

Your Local Pain Clinic

Email*

Yes, subscribe me to your newsletter.

alfatherapy@icloud.com

614-623-6077

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