Available by Appointment
Al Tin Winn ~ Nationally Certified Massage Therapist
Al specializes in therapeutic massage techniques including deep tissue release and myofascial release which greatly aid in the recovery from injuries, pain and tightness. Al can often heal minor injuries such as sprained ankles in a single session.
Massage Types:
Sports Massage
Deep Tissue
Active Isolated Stretching
Neuromuscular Therapy
Muscle Energy Technique
Accupressure
Reflexology
Reiki
Pricing:
30 Minutes: $50
60 minutes: $100
90 Minutes: $150
Appointments:
Please call The Next Level to make a therapeutic massage appointment: 240-497-1460.
Please arrive about 15 minutes prior to your first session to fill out a health form and discuss your needs with Al.
Client Information Form
Name: _______________________________________________________
Address: _____________________________________________________
City: ______________State: _________________Zip: ________________
Home phone: ___________________Work phone: ____________________
Cell phone: _____________________ Email: ________________________
Date of Birth: ________________Sex: Male_______ Female ____________
Have you ever had a professional massage? Yes _____ No _____
Primary reason for massage ? ____________________________________
_____________________________________________________________
Are you currently under chiropractic care? Yes _____ No ______
How were you referred to me? ____________________________________
What is your occupation? ________________________________________
Do you regularly exercise or participate in sports? Yes _____ No _____
If yes, describe the activities and frequency: _________________________
_____________________________________________________________
List any hobbies or regular activities: _______________________________
_____________________________________________________________
Do you eat a balanced diet? Yes _____ No _____
Rate your normal stress level (1 low – 10high) _____________
Rate your general consumption of the following:
Alcohol: Heavy ______ Moderate _______ Light _______ None _________
Caffeine: Heavy ______ Moderate _______ Light _______ None ________
Tobacco: Heavy ______ Moderate _______ Light _______ None ________
Sugar: Heavy ________ Moderate _______ Light _______ None ________
Physician Name: __________________ Phone: ______________________
Date of last exam: ___________________
Are you currently under a Doctor’s care? Yes _____ No ______
If yes, please describe:___________________________________________
_____________________________________________________________
Have you been hospitalized in the last year? Yes ______ No ______
If yes, please describe: ___________________________________________
________________________________________________________________________
Do you wear contact lenses:_______Dentures:___________Prosthesis:_________
Are you pregnant? Yes:_____No:_____If yes, due date:_____________________
Rate your general health
Excellent:______Good:______Fair:______Poor:________
List your primary areas of discomfort or tension:___________________________
__________________________________________________________________
Please check any of the following conditions you have:
Allergies_____Arthritis_____Blood clots______Carpal tunnel syndrome________
Circulatory problems_________Contagious disease_________Diabetes_________
Heart disease_________High blood pressure________Joint problems___________
Low blood pressure______Muscular injuries______Respiratoty problem________
Skeletal injures_______Skin problems________Spinal problems_______Varicose veins______Other____________________________________________________
Please describe the condition(s):________________________________________
__________________________________________________________________
Please check and chronic synptoms you have:
Abdominal pain________Chest pain________Constipation________
Digestive problems________Dizziness________Depression________
Fatigue_________Insomnia_________Migraine headaches_________
Sinusitis________Other_____________________________________
Please describe the symptom(s):_________________________________________
__________________________________________________________________
Is there anything else I should know about you, your health or your body before administering massage therapy?_________________________________________
__________________________________________________________________
I understand massage therapy is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow.
I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist does not prescribe medical treatment or pharmaceuticals.
To best accomplish maximum relief and increased range of motion: stretches and deep tissue massage techniques will most often be used. In doing so, your arms, legs, and body will be moved. To minimize exposure and make you most comfortable and at ease, I ask that you wear underwear.
In addition, if you have any other concerns or sensitivities, or specific requests, please let me know so I can do my best to accommodate you.
I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on my physical health.
I understand that if I am unable to keep my scheduled appointment, I am required to give 24 hours notice. If I do not call or show for a scheduled appointment I will be charged for the full payment.
Signature:_____________________________Date:_____________________________
THE NEXT LEVEL
5420 Butler Road
Bethesda, MD 20816
Winn.clinic@cox.net
