Breast Massage Consent & Health History

2. Do you ever experience breast pain or discomfort?* required

Yes

No

4. Breast discomfort: Does it change with your menstrual cycle or with hormone fluctuations?

Yes

No

I don't experience breast discomfort

I am in menopause

5. Would you like to receive breast massage from Jennifer Gibson LMT?

Yes

No

6. Have you had Professional Breast Massage or lymphatic work in the past?* required

Yes

No

Not sure

7. Check all that apply. I consent to receiving massage...* required

Over my loose fitting clothes

With bra removed

Through a sheet

Directly on my skin, undraped

Other

8. Check all that apply. I consent to receiving massage on the following areas around my breasts..... (Please know that you may ALWAYS change your mind during a session, no explanation needed)* required

Main Breast Tissue

Nipples

Areolae

Tissue near or in the armpits

11. Have you had any of the following imaging/tests on your breasts:* required

Mammogram

Ultrasound

Thermogram

MRI

Other

I have not received any of the above

12. Have you ever had breast surgery? * required

Yes

No

13. What type of breast surgery?* required

Lumpectomy

Mastectomy

Biopsy

Reconstruction

Augmentation

Other

I have had no surgery on my breasts.

14. Which breast(s) was the surgery performed on?

Right

Left

Both

15. Do you have breast implants? Which type?* required

No. I do not have breast implants.

Yes. Saline type.

Yes. Silicone type.

Yes. Flap type.

18. Have you had radiation treatment?* required

Yes

No

19. Have you had lymph nodes removed? * required

Yes

No

21. Pregnancy/Giving Birth (Please check all that apply to you)* required

I am currently pregnant

I am trying to become pregnant

I have been pregnant in the past

I have given birth

I have received a C-section surgery

None of the above