Confidential Health History Form

Confidential Health History Form

Please fill out this for to the best of your ability. All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
Full Name

First NameMiddle NameLast Name
Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number
This is my:
E-mail
Click here to subscribe to CedarOak's newsletter
Emergency Contact*
Phone Number*
1. What is your primary need with your massage session today?
2. In order of importance, list the main areas of your body that are painful, stiff, sore, or need attention.
3. In the above areas of concern, how did it come about? When did it start?
4. List any major surgeries and dates.
5. List any recent injuries or accidents.
6. Do you have any ongoing conditions that you deal with on a regular basis? If yes please explain.
7. List any medications you are currently taking.
8. Please list any symptoms or conditions you have in the following categories:
Please select the following sensitivities that apply to you

HeatColdLightNoiseOdorsTicklishnessEasily BruisedClosed SpacesDeep Pressure
Please list any areas of the body you would not like massaged (the groin area, gluteal cleft, and breast tissue will NEVER be exposed or massaged during the session).
Please list any areas of the body you would like extra attention paid to during the massage.
What questions do you have about the massage or the massage session?
Should be Empty: