Home
Massage
Book a Massage
Therapeutic Massage
The Myo
Deep Tissue Massage
Swedish Massage
Sports Massage
Prenatal Massage
Ashiatsu Massage
The Myo Jr.
Specialty Massage
Lymphatic Drainage
Cranio-Sacral Therapy
Thai Massage
Zero Balancing
Pain Management
Add-Ons / Facials
Aromatherapy
Facials
Head Trip
Hot Stone Massage
Packages & Specials
Couples Massage
Romance Retreat
Sweet Surprise
Mom To Be
The Myo Package
Fountain of Youth
Couples Massage Classes
Movement
Group Class Schedule
Yoga Classes
Iyengar Yoga Rope Wall
Iyengar Yoga for Hips
Somatic Flow Yoga
Slow Flow Yoga
Sound Healing and Meditation
Restorative Yoga
Other Classes
Feldenkrais
Pilates Fit
Postural Alignment and Somatic Integration
Floor Barre
Core Barre
HIGHbrid Workout
Workout! with Erica Nix
Private Classes / PT
Feldenkrais Functional Integration®
Private Pilates
Private Yoga
Workshops & Events
Acupuncture
Book Acupuncture
Lauren Brinkowski, L.Ac, MAOM
Lauren’s Approach to Treatment
Acupuncture FAQ
About Us
Our Therapists
Our Instructors
Find Your Treatment
Memberships
Video Tour
FAQs
Policies
Jobs at Myo
Contact
Memberships
512-458-4696
Book Online
Gift Cards
Home
Massage
Book a Massage
Therapeutic Massage
The Myo
Deep Tissue Massage
Swedish Massage
Sports Massage
Prenatal Massage
Ashiatsu Massage
The Myo Jr.
Specialty Massage
Lymphatic Drainage
Cranio-Sacral Therapy
Thai Massage
Zero Balancing
Pain Management
Add-Ons / Facials
Aromatherapy
Facials
Head Trip
Hot Stone Massage
Packages & Specials
Couples Massage
Romance Retreat
Sweet Surprise
Mom To Be
The Myo Package
Fountain of Youth
Couples Massage Classes
Movement
Group Class Schedule
Yoga Classes
Iyengar Yoga Rope Wall
Iyengar Yoga for Hips
Somatic Flow Yoga
Slow Flow Yoga
Sound Healing and Meditation
Restorative Yoga
Other Classes
Feldenkrais
Pilates Fit
Postural Alignment and Somatic Integration
Floor Barre
Core Barre
HIGHbrid Workout
Workout! with Erica Nix
Private Classes / PT
Feldenkrais Functional Integration®
Private Pilates
Private Yoga
Workshops & Events
Acupuncture
Book Acupuncture
Lauren Brinkowski, L.Ac, MAOM
Lauren’s Approach to Treatment
Acupuncture FAQ
About Us
Our Therapists
Our Instructors
Find Your Treatment
Memberships
Video Tour
FAQs
Policies
Jobs at Myo
Contact
Memberships
Home
Massage
Book a Massage
Therapeutic Massage
The Myo
Deep Tissue Massage
Swedish Massage
Sports Massage
Prenatal Massage
Ashiatsu Massage
The Myo Jr.
Specialty Massage
Lymphatic Drainage
Cranio-Sacral Therapy
Thai Massage
Zero Balancing
Pain Management
Add-Ons / Facials
Aromatherapy
Facials
Head Trip
Hot Stone Massage
Packages & Specials
Couples Massage
Romance Retreat
Sweet Surprise
Mom To Be
The Myo Package
Fountain of Youth
Couples Massage Classes
Movement
Group Class Schedule
Yoga Classes
Iyengar Yoga Rope Wall
Iyengar Yoga for Hips
Somatic Flow Yoga
Slow Flow Yoga
Sound Healing and Meditation
Restorative Yoga
Other Classes
Feldenkrais
Pilates Fit
Postural Alignment and Somatic Integration
Floor Barre
Core Barre
HIGHbrid Workout
Workout! with Erica Nix
Private Classes / PT
Feldenkrais Functional Integration®
Private Pilates
Private Yoga
Workshops & Events
Acupuncture
Book Acupuncture
Lauren Brinkowski, L.Ac, MAOM
Lauren’s Approach to Treatment
Acupuncture FAQ
About Us
Our Therapists
Our Instructors
Find Your Treatment
Memberships
Video Tour
FAQs
Policies
Jobs at Myo
Contact
Memberships
Massage Intake Form
Intake form
First Name
*
Last Name
*
Nickname
Date of Birth
*
format must be xx/xx/xxxx
Email Address
*
Phone Number
*
Address
Zip Code
*
Occupation
Emergency Contact Name
Emergency Contact Phone Number
Gender
Female
Male
Non-Binary
Other
Other
What pronouns do you use?
e.g. she/her, he/him, they/them, etc
How did you hear about us?
Yelp
Google search
Facebook
Another client
Another health provider
Received a gift certificate
Won/purchased a certificate at a fundraiser
Flyer/Coupon
Saw us at Triangle
Other
Other
Who referred you specifically?
Are you currently experiencing any of the following conditions?
Fever/Chills
Sore Throat
Other Flu/Cold/COVID symptoms
Other Contagious Disease
Recent Injury/Accident
Open Sore/Wound
Inflammation
Infection
Nausea
Dizziness
Please mark conditions which apply to your present health or with which you have a significant history:
Headaches
Herniated Disk
High Blood Pressure
Cancer
Chronic Pain
Fractures
Low Blood Pressure
Lymphedema
Arthritis
Whiplash
Blood Clots
Diabetes
Fatigue
Tendonitis/Bursitis
Heart Disease
Endocrine Disorders
Fibromyalgia
Sprains/Strains
Varicose Veins
Digestive Disorders
Osteoporosis
TMJ/Jaw Pain
Psoriasis
Auto-immune disorders
Scoliosis
Sciatica
Eczema
Sleep Disorders
Spinal Cord Injury
Carpal Tunnel/RSI
Fungal Infections
PTSD
Stroke
Numbness/Tingling
Allergies
Depression
Seizure Disorders
Nerve Pain
Asthma
Anxiety
Other
Other
Other
Other
Other
Other
Other
Other
Please describe current conditions and past surgeries, accidents, injuries, concussions, fractures, major illnesses, or current medical conditions.
Please select any areas where you are currently or habitually experiencing pain or tension:
Head
Right Shoulder
Right Wrist
Right Thigh
Neck
Left Shoulder
Left Wrist
Left Thigh
Upper Back
Right Arm
Right Hand
Right Knee
Mid Back
Left Arm
Left Hand
Left Knee
Lower Back
Right Elbow
Right Hip
Right Calf
Sacrum
Left Elbow
Left Hip
Left Calf
Chest
Right Ankle
Right Foot
Other
Other
Abdomen
Left Ankle
Left Foot
Other
Other
Please add any details about affected areas:
Do you have any known allergies or chemical sensitivities?
Yes
No
What are you allergic or sensitive to?
Are you currently pregnant or attempting to conceive?
Yes
No
Planning
If pregnant, when are you due?
Next
Comments are closed.
