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Hot Stone Intake Form

This is a copy of the intake form that you will be asked to fill out before receiving hot stone massage. It is to insure that you have a safe and comfortable massage.

Hot stone massage is not suitable for everyone. Please review the list of contraindications below. If any of these conditions apply to you, then you should not receive hot stone massage.

*Blood clots / prone to blood clots
*Bruise easily
*Cancer, chemotherapy or radiations treatments
*Depressed immune system
(lupus, HIV/AIDS, cancer, Epstein Barr, mononucleosis, fibromyalgia, chronic fatigue, etc.)
*Diabetes
*Fever
*Heart problems
*Heat Sensitivity
*High Blood Pressure
*Inflamed Skin Conditions
*Nerve Trauma
*Neuropathy
*Open wounds or sores
*Peripheral vascular disorder
*Pregnancy
*Recent Surgery
*Taking medications that have side effects to heat
(Please check with your pharmacist if you are not certain.)
*Varicose veins

*If you have any doubt that hot stone massage is safe for you, please check with your doctor before receiving this modality.

Please print your name neatly and sign below to indicate that you have read the above contraindications and do not have any conditions that would prohibit a safe hot stone massage.


Print full name _____________________________________


Signature _________________________________________

Other pages:

TRANQUIL TOUCH MASSAGE OF SAN RAMON, CA
Tranquil Touch Massage Therapy, Located in San Ramon California. Acupressure, Cranio-Sacral, Deep Tissue, Fibromyalgia Massage, Hot Stone, Indian Head Massage, Prenatal Massage, Reiki, Reflexology, Swedish and Trigger Point.
OFFICE LOCATION
Map and Directions to Tranquil Touch Massage Therapy. Located in San Ramon California. Close to Blackhawk, Danville, Dublin and Castro Valley.
SESSION PRICES
Acupressure, Swedish, Deep Tissue, Hot Stone, Reiki and Couples Massage available in our massage studio located in San Ramon California.
GIFT CERTIFICATES
Massage Gift Certificates available for purchase at our office in San Ramon California, or call us and we will mail them to you.
WHAT TO EXPECT FROM YOUR MASSAGE
Frequently asked questions about the massage session.
CONTRAINDICATIONS
When massage should not be performed.
ARE YOU IN PAIN?
Relief from carpal tunnel syndrome, fibromyalgia, headaches, leg cramps, lower back pain, migraines, neck and shoulder pain, sciatica, and stress related disorders.
ARE YOU STRESSED OUT?
Chronic stress leads to health problems. Regular massage can relieve stress and teach your body to relax.
MASSAGE FOR FIBROMYALGIA
Information on fibromyalgia and links to online resources.
WHERE DO I FIND THAT?
Products and Services that I recommend to my clients.
SAN RAMON WEBSITES
Links to resources in and around San Ramon.
Hot Stone Intake Form
A list of contraindications to Hot Stone Massage
MY BLOG
Here you will find information regarding health and well being that is not massage related.

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