MASSAAHG Experience Health History and Terms of Service Agreement: 2025

Welcome to MASSAAH'G Bodywork and Coaching. Your well-being is our primary focus. This Health History Form provides essential information needed to create your personalized healing experience tailored to your unique needs.

PRIVACY POLICY & DATA PROTECTION
Effective JUNE 20, 2025

Information Collection: We collect financial and personal health information necessary for payment processing and service delivery across our comprehensive offerings including massage therapy, nutrition coaching, and wellness programs.

Information Use: Your data is used exclusively for:

  • Service delivery and quality monitoring

  • Secure payment processing

  • Legal compliance requirements

Information Protection: We employ industry-standard security measures to prevent unauthorized access or misuse. Your information is never shared with third parties except for secure payment processing or emergency situations.

Data Retention: Information is retained only as long as required for service delivery and legal compliance, then securely disposed.

Your Rights: You may access, amend, or request removal of your information at any time.

Policy Updates: We will notify you of significant policy changes via our website or direct communication.

Contact Information:

Alyssa Miller-Nelson, LMT, NMT, CPT, CNC, C.Ht

Office: 15433 S. Calle Tunal Sahuarita, Arizona 85629

Direct Call/Text: 1 (520) 440-2446 | Office: 1 (231) 444-4525

Email: [email protected]
Website: www.sahuaritamobilemassaahg.com

ACKNOWLEDGMENT & CONSENT

By completing and dating this Health History Intake Form, you:

  • Acknowledge understanding of our privacy practices

  • Consent to the collection and use of your information as described

  • Agree to keep us updated regarding changes to your health and contact information

First, M, LAST
with Area Code 
Full street Mailing address
Past injuries? Surgeries? Mental/Emotional? etc.?

Physical Activity Readiness Questionnaire

Health Conditions: Signs, Symptoms, Location

Symptoms: Which do you experience? Fatigue, weight issues, hair loss, cold hands/feet, brain fog, mood changes, digestive problems, sleep disturbances, chronic pain?

Physical Activity: Exercise routine, repetitive movements at work/hobbies, hours sitting daily, areas that bother you during movement.

Additional Information: Anything else important for me to know about your health history, goals, or concerns? Theis information will help me determine if there are specific techniques or modalities most suitable - or not - for your specific situation.

Examples of Health Conditions:

Check if you have any that apply and please specify any pertinent details:

  • Musculoskeletal: Back pain, joint issues, arthritis, fibromyalgia

  • Heart/Circulation: High blood pressure, heart disease, circulation problems

  • Respiratory: Asthma, COPD, allergies, sleep apnea

  • Thyroid/Hormonal: Hypothyroid, hyperthyroid, Hashimoto's, menstrual issues, menopause

  • Digestive: IBS, GERD, food allergies, constipation

  • Nervous System: Migraines, neuropathy, concussion

  • Mental Health: Depression, anxiety, PTSD

  • Other Conditions: Diabetes, autoimmune, chronic fatigue, cancer history, etc.

Terms of Service Consent to Treat &

Client Agreement - 2025

1. CONSENT TO RECORDING

By typing "I Agree" or "I Accept," and signing, you consent to the recording of all consultations conducted via Zoom, Google Meet, or telephone for quality assurance, training purposes, and accurate record maintenance.

2. SERVICE DELIVERY & SCOPE

Location & Capabilities: Services are provided from a home office location with mobile therapeutic and remote coaching capabilities.

Service Refusal Rights: MASSAAH'G reserves the right to refuse service to any individual to ensure safety and security of all parties, particularly regarding health, well-being, and human trafficking concerns.

Service Classification: All services constitute Healing Educational Awareness Resources, Therapeutic Tools, Support Systems, and Strategies designed to support wellness and are NOT substitutes for professional medical care, examination, diagnosis, or treatment.

3. HEALTH & SAFETY REQUIREMENTS (PAR-Q BASED)

Immediate Health Communication: You must immediately notify Alyssa Miller-Nelson, LMT, NMT, CPT, CNC, CHT, of any of the following:

  • Adverse reactions or concerns regarding your well-being from treatment initiation through four (4) days post-treatment

  • Changes in your health status, medications, or medical conditions

  • Discomfort, pain, or unusual symptoms during or after sessions

Medical Clearance: If you have answered "YES" to any PAR-Q questions or have specific health conditions, you may be required to obtain medical clearance before services can be provided.

Health History Accuracy: By selecting, "I Agree," You certify that all health information provided is complete, accurate, and truthful to the best of your knowledge.

4. CLIENT RESPONSIBILITIES & PARTICIPATION

Active Healthcare Partnership: You acknowledge your critical role as part of your healthcare team and agree to:

  • Fully engage in prescribed self-care programs

  • Adhere to mutually agreed treatment plans

  • Maintain honest communication regarding treatment plan changes

  • Report any concerns, limitations, or challenges promptly

    Informed Consent: You understand that therapeutic bodywork and coaching may involve physical contact modalities and techniques and may involve emotional processing. You consent to receive any and all of these experiences through our services.

5. PROFESSIONAL BOUNDARIES & LIMITATIONS

Scope of Practice: Services provided fall within the scope of massage therapy, neuromuscular therapy, personal training, nutrition coaching, and hypnotherapy as licensed/certified in Arizona.

Medical Disclaimer: These services are complementary to, not replacements for, conventional medical care. You are encouraged to maintain regular contact with your primary healthcare provider.

Emergency Situations: In case of medical emergency during sessions, appropriate emergency services will be contacted immediately.

6. CONFIDENTIALITY & PRIVACY

Protected Information: All health information, session notes, and personal details shared are confidential and protected under professional privacy standards.

Information Sharing: Health information will only be shared with other healthcare providers with your written consent or as required by law.

7. ACKNOWLEDGMENT AND AGREEMENT

By accepting these Terms of Service and Signing below, you certify that you have:

Read and understood all terms and conditions outlined above

Answered all health history questions truthfully to the best of your knowledge

Agreed to maintain honest communication regarding your health status and treatment responses

Committed to active participation in your healthcare and wellness journey

Understood the scope and limitations of services provided

Consented to receive therapeutic bodywork and coaching services