Health History Form
Name
*
First Name
Last Name
Age
*
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Relationship
*
Health Information
Do you have any allergies?
*
If yes, please specify on the field above.
Are you currently taking any medications?
*
If yes, please specify on the field above.
(Female Only) Are you pregnant? How many weeks?
If yes, please specify on the field above.
(Female Only) Postpartum? How many weeks?
The postpartum period is considered the first 12 weeks after delivery
Have you been recently hospitalized?
*
If yes, please specify on the field above.
Do you have any current injuries?
*
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, Epilepsy, Scoliosis, Communicable disease, etc.?
*
If yes, please specify on the field above.
Location of painful areas
*
Include any areas you experience pain or discomfort
Do you experience tension headaches or migraines? If YES list known triggers
What are your goals for this treatment session?
*
How did you hear about us?
*
Who were you referred by? Do you have a gift certificate?
Consent and Waiver
Type a question
*
I acknowledge that all information I provided in this form is true and accurate.
I affirm that I have notified my therapist of all known medical conditions and injuries.
I agree to inform the therapist of any changes in my health and medical condition.
Signature of the Client
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: