1. Name:*

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

3. Breast discomfort: If yes, when do you typically feel this pain?

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

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

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

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

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)*

9. Do you perform a thorough breast self-check? If so, how often *

10. When were your breasts last examined by a physician?*

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

12. Have you ever had breast surgery? *

13. What type of breast surgery?*

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

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

16. Have you ever been diagnosed with lumps, cysts or fibrocystic breasts? Please explain.*

17. Have you been diagnosed with breast cancer? If so when? Are you still receiving treatment?*

18. Have you had radiation treatment?*

19. Have you had lymph nodes removed? *

20. Have you nursed or are nursing? If yes, how long?*

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

22. Consent: By typing my FULL NAME below, I give Jennifer Gibson LMT of Wild Sage Bodywork permission to perform breast massage as I have consented to on this form.*

23. Today's Date:*

24. Consent: By typing my FULL NAME below, I acknowledge the understanding that I can change my mind at any time and relinquish consent verbally during a session with Jen. *

25. Today's Date: