NX Sculpt
NX Sculpt

Manual Therapy & Body
Treatment Consent Form

Please complete your health history and treatment areas.

Step 1Step 2

Client Information

Health History

Health conditions or concerns:

Contraindications & Treatment Limitations

I understand that treatment may be modified, postponed, or refused based on my condition.

General contraindications: Treatment will not be performed in cases of fever, infectious diseases, acute inflammation, open wounds, bruises, or severe undiagnosed pain.

MYOFASCIAL RELEASE (MFR)

Please indicate the areas where you feel pain, tension, tightness, or discomfort.

Tap or drag on the body diagrams below to mark with an "X" where you feel pain and where it radiates.

Front

Front

Back

Back

Left Side

Left Side

Right Side

Right Side

MFR: Affected Areas

LYMPHATIC DRAINAGE (MLD)

Please indicate the areas where you feel swelling, heaviness, or discomfort.

Tap or drag on the body diagrams below to mark with an "X" where you feel swelling, heaviness, or discomfort.

Front

Front

Back

Back

Left Side

Left Side

Right Side

Right Side

MLD: Affected Areas