Beyond Massage Aspen
  • Services
    • Massage
      • Traditional Thai Massage
      • Neuromuscular / Trigger Point (Therapeutic)
      • Myofascial Release
      • Ashiatsu Oriental Bar Therapy®
      • Deep Tissue Massage
      • Reflexology
      • Prenatal Massage
    • Acupuncture
      • Orthopedic Acupuncture Intake Form
      • What to Expect
    • Therapeutic Injections
      • Learn More
      • B-12 Injections
    • Functional Medicine Testing
      • Vitamin Deficiencies
      • Adrenal/Cortisol/Hormone Testing
    • Natural Pharmacy
      • Order Now
  • About
    • Erica Boulangee
  • Classes
    • Upcoming Classes
    • Instructors
      • Erica Boulangée
      • John Schmidt
      • Natalie Gentry
      • Benny Vaughn
      • Sally Klemm
      • Deane Juhan
  • Shop
    • Gift Certificates
    • Natural Pharmacy
  • Contact
  • Schedule Apt.
  • Menu Menu

Step 1 of 5

20%
  • Client Info

  • Date Format: MM slash DD slash YYYY
Save and Continue Later
  • History

    Background Information on Primary Complaint
  • To better understand the role of acupuncture and Oriental medicine in the care of your primary complaint, I am interested to know what other types of health care professionals you have consulted in the past AND are consulting currently regarding your primary complaint. Please check ALL that apply.
  • What other forms of treatment are you CURRENTLY using specifically for your primary complaint?
Save and Continue Later
  • Specific Information on Primary Complaint

  • IMPACT ON WORK ACTIVITIES
  • Are you experiencing any of the following issues with your work (inside and outside of the home) by your primary complaint?
  • IMPACT ON SOCIAL ACTIVITIES
  • IMPACT ON EXERCISE ACTIVITIES
  • Are you experiencing any of the following issues with your usual exercise regimen by your primary complaint?
Save and Continue Later
  • General Health & Well Being Questions:

  • Please use the following letters to indicate if you have any of the following symptoms:

    Sleep:
  • Digestion
  • General
  • Energy
  • Bowel Elimination
  • Emotional State
  • Respiratory
  • Urination
  • Respiratory
  • Eyes
  • Mouth
  • Nose
  • Ears
Save and Continue Later
  • Consent to Treatment of Minor

  • Because the selected age was below 18, a parent or guardian signature is required. br />
    By my signature below, I hereby authorize beyond massage Aspen Staff to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.
Save and Continue Later

Stay up to date with our Newsletter

Beyond Massage Aspen

Address:
300 S. Spring St. Suite 203
Aspen, CO 81611

Phone:
(970) 274-8717

Office Hours

Mon: 11am-7pm
Tue: 11am-7pm
Wed: 11am-7pm
Thu: 11am-7pm
Fri: 11am-6pm

 

© Copyright - Beyond Massage Aspen. All rights reserved. Site Built By: Overhaulics
  • Facebook
  • Twitter
  • Rss
Scroll to top