General Information
Name: __________________________________________________________
Date: _____________________________________
Address: ________________________________________________________________________________________________________
City and State: ___________________________________________________ Zip code: ____________________________________
Home Phone/Cell Phone: _____________________________________ Other Phone: _____________________________________
Email: ___________________________________________________________
D.O.B: ______________________________________
Work Information
Work Phone: ___________________________________ Occupation: ___________________________________________________
Type of Work (Desk, Computer, Physical…) ________________________________________________________________________
Lifestyle Information
Do you exercise? If yes, doing what: _____________________________________________________________________________
How often, and for what duration: ________________________________________________________________________________
Prescription and Non-Prescription Medications, and Supplements and Vitamins: ____________________________________
_________________________________________________________________________________________________________________
Food Allergies: ___________________________________________________________________________________________________
Emergency Information
Emergency Contact: ________________________________________________ Day Phone: _______________________________
Relationship: _____________________________________________________ Evening Phone: ______________________________
General Massage Information
How did you hear about Peace of Werk? _________________________________________________________________________
Have you received professional massage or bodywork before? Yes / No
How often? __________________________
Type of massage and/or bodywork received? ____________________________________________________________________
Are there any areas you DO NOT wish to receive massage? _______________________________________________________
What type of pressure do you prefer? (Light, Firm, Relaxation, Therapeutic, ….) _____________________________________
Allergies to nuts, creams, oils or lotions? ___________________________________________________________________________
Page 1 of 4
© Peace of Werk LLC. All rights reserved.
Please mark (X) for current conditions and mark (P) for past conditions
Please add comments for clarification
Musculo-Skeletal
___ Headaches
___ Migraines
___ Joint stiffness/swelling
___ Spasms/cramps
___ Broken/fractured bones
___ Sprains/strains
___ Back, hip pain
___ Shoulder, neck, arm, hand pain
___ Leg, foot pain
___ Chest, ribs, abdominal pain
___ Problems walking
___ Jaw pain/TMJ
___ Tendinitis
___ Bursitis
___ Arthritis
___ Osteoporosis
___ Scoliosis
___ Bone or joint disease
___ Unsteady gait
___ Frequent falls
___ Comments:
Circulatory and Respiratory
___ Dizziness
___ Shortness of Breath
___ Persistent cough/wheeze
___ Short of breath with exertion
___ Fainting
___ Cold hands or feet
___ Cold sweats
___ Swollen ankles
___ Pressure Sores
___ Varicose veins
___ Blood clots
___ Phlebitis
___ Stroke
___ Heart condition
___ Allergies
___ Sinus problems
___ Asthma
___ High / low blood pressure Circle
___ Lymphedema
___ Easily bruising / bleeding Circle
___ Comments:
Skin
___ Rashes/lumps
___ Allergies
___ Athlete’s Foot/fungal infection
___ Warts
___ Moles
___ Acne
___ Cosmetic surgery
___ Boil
___ Eczema
___ Psoriasis
___ Burns
___ Comments:
Digestive
___ Nervous stomach
___ Indigestion
___ Constipation
___ Heartburn
___ Intestinal gas/bloating
___ Diarrhea
___ Diverticulitis
___ Irritable bowel syndrome
___ Crohn’s Disease
___ Colitis
___ Adaptive aides
___ Comments:
Nervous System
___ Numbness/tingling
___ Facial twitching
___ Fatigue
___ Chronic pain
___ Sleep disorders
___ Ulcers
___ Paralysis
___ Herpes/shingles
___ Cerebral Palsy
___ Epilepsy
___ Chronic Fatigue Syndrome
___ Multiple Sclerosis
___ Muscular Dystrophy
___ Parkinson’s disease
___ Spinal cord injury
___ Comments:
Reproductive System
___ Pregnancy
___ Current ___ Previous
___ PMS
___ Menopause
___ Pelvic Inflammatory Disease
___ Endometriosis
___ Hysterectomy
___ Fertility concerns
___ Prostate problems
Other
___ Frequent nose bleeds
___ Heat or cold sensitivity
___ Excessive sweating
___ Loss of appetite
___ Forgetfulness
___ Confusion
___ Depression
___ Difficulty concentrating
___ Drug use:
___ Alcohol use:
___ Caffeine use:
___ Hearing impaired
___ Visually impaired
___ Burning upon urination
___ Bladder infection
___ Eating disorder
___ Diabetes
___ Thyroid Imbalance
___ Fibromyalgia
___ HIV/AIDS
___ Cancer:
Please ask for Oncology Intake
___ Infectious Disease Please List
___ Other disability Please include
accommodation request
___ Surgeries:
___ Other Health Condition:
For clients who need mobility
assistance, please provide your:
Height: _______ Weight: ______
Page 2 of 4
© Peace of Werk LLC. All rights reserved.
Session Time
At Peace of Werk we practice flexible sessions; both in session time and treatment plan. This means that your session
time can range anywhere from 30 - 110 minutes depending on the type of treatment and session goals. In additional,
a variety of modalities may be utilized. Ala Carte session time is $1/minute, all modalities included.
If you have a time constraint, limitation or a modality you are not comfortable with please inform your therapist.
Session time starts upon entering the treatment room. We encourage all personal conversations to be held within our
front reception room, either prior or post treatment. To be true to our flexible sessions, we allow the client to dictate
the pace at which healing happens. We value this type of treatment, and want to be able to allow as much time as
necessary for healing in whatever format our client needs: intake, assessment, table time, mindfulness, wellness
practices.
To receive your full session time, please arrive on time or a few minutes early to complete intake form. If you arrive late,
we cannot extend your appointment time beyond your scheduled time block. Your treatment will continue as the
time block allows.
Interested in Weekly Massage?
Join our Membership Community! For a monthly due of $300 you receive the benefits of continual massage up to
twice per week! Two ways to utilize our Complete Eudaimon Healing Membership:
Weekly with Your Favorite Therapist
Schedule a standing weekly appointment with your favorite Healer! You may also have ONE additional appointment
scheduled ad hoc with the same or different healer*.
Healing to the Max; As many as you can get!
Up to FOUR scheduled sessions at any given time, as often as you can match our schedule to yours!*
You may start a membership at your scheduled session to include the days treatment into your month of healing! To
start your membership inform your therapist or sign up on our website at www.peaceofwerk.com.
Gratuity not included in membership price. Please ask if you have questions or visit our website for more information.
*Please respect our membership policies: Allow a full 72-hours between sessions, all office policies still apply such as short notice cancellation,
and adhere to our scheduling policies; standing appointment plus ONE ad hoc treatment or FOUR ad hoc treatments.
Any sessions booked within 72-hours of each other will be cancelled. Sessions above booking limit will be cancelled. Membership services
start at date of purchase and continue consecutively. Membership value is not transferable, and may only be used by named
purchaser. Only one user per membership is allowed. All appointment cancellations due to policy violation will be notified by email.
Ask how to create an online account to schedule, change, or cancel appointments 24/7 from any web browser!
Short Notice Cancellation and Session No Show
At Peace of Werk we require a minimum 24-hour advance cancellation notice. Appointment day cancellation or no
show will be subject to a cancellation fee. If you need to cancel or re-schedule your appointment please use your
registered account access, contact Peace of Werk at: 855.608.WERK (9375) or call/text your Healer directly.
Cancellations made by e-mail with 24-hour window will not be accepted. All cancellation fees must be paid before
you are eligible to receive treatment. Failure to adhere to policies and fees will not result in a refund for membership,
nor is Peace of Werk liable for services not rendered due to failure to pay policy fees.
Booster Session Short Notice Cancellation Fee: $15
Booster Session No Show Fee: $45
Full Body Treatment Short Notice Fee: $35
Full Body Treatment No Show Fee: $75
Intensive Healing Short Notice Fee: $75
Intensive Healing No Show Fee: $150
Page 3 of 4
© Peace of Werk LLC. All rights reserved.
Information and Suggestions for the Client
Prior to your massage, please remove all jewelry. Massage is usually given while you are unclothed. We provide a
top sheet and blanket for modesty and comfort. You may choose to wear undergarments or a swim suit or nothing
at all. Please honor your comfort level.
During your massage, you may want to give your therapist feedback as to pressure (deeper or lighter) or point out
painful or ticklish areas of your body. This will not only improve your experience, but also improve your session results.
Feel free to ask your Healer any questions about their procedure. They will be happy to make you feel well informed
and comfortable.
Informed Consent
Please take a moment to carefully read the following information and sign where indicated.
I, ______________________________________ Print Name, understand that massage therapy provided at Peace of Werk LLC
is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve
circulation, increase energetic vitality, and offer a positive experience by touch. If I experience pain or discomfort
anytime during my session I will notify my therapist immediately so the treatment can be adjusted to match my comfort
level.
I am aware that certain side effects may result from my treatment including, but not limited to: bruising, sore muscles,
and the possibility of aggravation of symptoms existing prior to treatment.
I have informed Peace of Werk LLC of all my known physical conditions, medical conditions and medications. I will
update Peace of Werk on any changes to my health history, allergies or medications, and understand that there shall
be no liability on the provider’s part should I fail to do so.
It is understood that any illicit or sexually suggestive remarks or advances made will result in immediate termination of
the session, and I will be liable for payment of the scheduled appointment.
By signing below I consent to receive treatment and understand the possible massage contraindications. I
understand that massage therapy is not a substitute for medical treatment or medications, and that it is
recommended that I concurrently work with my Primary Caregiver for any condition I may have. I understand that
for some medical condition(s) and/or specific symptoms, massage may be contraindicated. A referral from your
primary care provider may be required prior to service. For pregnancy massage a written medical clearance note is
always required prior to treatment. I am aware that the massage therapist does not diagnose illness or disease and
does not prescribe medications.
I have read and understand Peace of Werk LLC policies and procedures outlined and agree to abide by them.
Should I have to cancel an appointment for any reason, I agree to provide 24-hour notice, or am liable for payment
of scheduled appointment.
___________________________________________________________________________
Client Signature
___________________________________
Date
___________________________________________________________________________
Parent or Guardian If under the age of 18.
___________________________________
Date
Page 4 of 4
© Peace of Werk LLC. All rights reserved.