This is how we work safely: tell us your goals and your health picture before the first session. Review it on screen, print it, or fill it out with us at your first visit. Everything on it is kept confidential.
Bourne Bodyworks · 818 Industry Place, Carbondale, CO 81623 · (970) 355-8790 · bournebodywork@gmail.com
Client information
Your goals for this work
Pressure you generally prefer: ☐ light ☐ moderate ☐ firm ☐ not sure — let’s find it together
Health history
Please check anything that applies now or in the recent past. A check doesn’t mean you can’t receive massage — it means we adapt the work, and in some cases we’ll ask your physician first.
Heart & circulation:☐ High or low blood pressure☐ Heart condition / circulatory issues☐ Stroke or TIA☐ Blood clots / DVT / clotting disorder☐ Blood-thinning medication☐ Varicose veins☐ Pacemaker / defibrillator / implanted device or port
Bones, joints & muscles:☐ Osteoporosis / low bone density☐ Arthritis (osteo / rheumatoid — circle)☐ Joint replacement / surgical hardware (which, when — below)☐ Recent injury, sprain, or fracture☐ Surgery in the last 12 months
Other conditions:☐ Diabetes☐ Asthma, COPD, or other breathing condition☐ Autoimmune / inflammatory condition (RA, lupus, fibromyalgia…)☐ Kidney or liver disease☐ Cancer (current or past)☐ Lymphedema / lymph-node removal☐ Skin conditions, rashes, or open wounds☐ Fever or contagious illness (past 48 hours)☐ Pregnant☐ Postpartum (past 12 months)☐ Allergies to oils, lotions, scents, or nuts☐ Other (below)
Head & neurological screening (matters for craniosacral & sports work)
☐ Concussion or head injury (when? — below)☐ Diagnosed or suspected aneurysm☐ Skull or facial fracture☐ Brain or spinal surgery, shunt, or implant☐ Recent spinal tap, epidural, or CSF issues☐ None of these
Medications
Have you taken pain medication, muscle relaxants, or anything else today that reduces sensation? ☐ yes ☐ no
If pregnant or postpartum
For our older-adult & longevity clients
Your care team
Are you currently working with a physician, physical therapist, or other provider for anything we’d be working around? ☐ yes ☐ no
If you’d like us to coordinate with that provider, we’ll ask for your separate written consent on the consent & provider-referral form. We never contact a provider without it.
Session location
Where will we work? ☐ in-studio (Carbondale) ☐ in-home
Staying in touch
You may contact me about appointments (confirmations, reminders, schedule changes) by: ☐ email ☐ text ☐ phone call Appointment messages only — never marketing without separate permission. You can change this anytime.
Client acknowledgment
I confirm the information above is true and complete to the best of my knowledge. I understand that massage therapy at Bourne Bodyworks is provided by a Colorado-licensed massage therapist, that it is not a substitute for medical care, and that the therapist does not diagnose or treat medical conditions. I agree to tell the therapist about any changes in my health before future sessions, and to speak up during a session about pressure, discomfort, or anything I’d like changed. My health information is kept confidential and is shared with another provider only with my separate written consent — except as required by law (for example, a court order or a mandatory report) or as needed to respond to a claim I bring. I may ask for a copy of my records at any time; the practice keeps intake and consent records securely for as long as law and professional-liability requirements make necessary.
If the client is under 18
How this fits with booking online. When you book through our booking calendar, you answer a short safety screen — roughly a dozen questions about anything that would change how we work with you that day. This page is the full health history, and we complete it together at your first visit. The screen is not a substitute for it: it exists to catch what cannot wait, not to replace the conversation. Bring nothing if you’d rather — we can fill this in together.
Note for the practice owner: this is general template language for demonstration only — remove this note only as part of attorney sign-off, never before. Have it reviewed by a qualified attorney or compliance professional to ensure it meets your state’s consent, privacy, and scope-of-practice requirements. Completed forms contain health information — store them in a locked file or secure clinical system, not loose or in ordinary email.