Inclusive Wellness Health History Form

Confidential Health History Form
*Please fill this form out to the best of your knowledge. All information stated in this form is confidential and will not be released without your written consent.
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name (First):
(Last):
Address

Address

Street Address Line 2

City/TownState / Province

Postal / Zip Code
Postal Code:
Province/State:
Primary Phone Number:
Emergency Contact:
Date of Birth (Day/Month/Year):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email:
example@example.com
Occupation
Current medications:
Have you had surgery in the past?
If yes, describe:
Any skin conditions or skin allergies?
If yes, describe:
Are you currently pregnant?
If yes, when is your due date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Did the current injury result from a motor vehicle accident or workplace injury?
If yes, describe:
Are you currently experiencing or have you experienced in the past any of the following? or dizziness skin conditions varicose veins crohn’s disease phlebitis/circulatory problems pelvic inflammatory disease headaches or migraine epilepsy neck injury nervous system disorders back injury whiplash jaw or ear pain stroke osteoporosis respiratory conditions rheumatoid arthritis diabetes: osteoarthritis other:
If other, explain:
I hereby consent to receive massage therapy and/or other modalities that are within the scope of a Registered Massage Therapist.
Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Confidential Health History Form