Health History Intake Form

Name

Date of birth

Date

Referred by

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physician's name

Physician's phone

Format: (000) 000-0000.

Emergency contact name and relationship

Emergency phone #

Format: (000) 000-0000.

Have you had a professional massage before?

How would you rate your general health?

List current medications & the conditions they are treating

List any major accidents or surgeries (including dates)

Please tell us about any allergies or hypersensitivities

Reason for initial visit

Sinusitis

RESPIRATORY

SKIN & INFECTIONS

NERVOUS SYSTEM

MUSCULOSKELETAL SYSTEM

REPRODUCTIVE

Anything else you would like me to know?

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of

Signature

Date

Name

First NameLast Name

Please check any current or past conditions that may influence your massage today