Medical History Form

Thank you for taking the time to complete this medical history form. Before you consent to receiving body work, please inform me of any contraindications you may be experiencing.

Thank you so much for complying. I look forward to working with you!

-Crystal

Name*

First NameLast Name

What are your pronouns? (They/them, She/her, He/him)

Date of birth*

Date

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

What brings you to the office? What would you like to address?*

Overall, how would you describe your physical health?*

Overall, how would you describe your mental & emotional health?*

What medications are you currently taking?*

Please list any past or recent injuries or surgeries.*

Please list any NEUROLOGICAL conditions you currently have, or have had in the past. (Example: Shingles, Seizures, Dizziness, Tingling, Parkinson's) :

Please list any CARDIOVASCULAR conditions you currently have, or have had in the past (Example: Heart Attack, Pacemaker, Lymphedema, Blood Clots, Vericose Veins):

Please list any IMMUNE conditions you currently have, or have had in the past. (Example: Allergies, Lupus, Cancer, Rheumatoid Arthritis) :

Please list any MUSCULOSKELETAL conditions you currently have, or have had in the past. (Example: Tendonitis, Gout, Artificial Joints, Osteoporosis, Scoliosis):

Please list any GASTROINTESTINAL conditions you currently have, or have had in the past. (Example: IBS, Crohn's Disease, Constipation, Eating Disorder):

Please list any BLOOD conditions you currently have, or have had in the past. (Example: HIV/AIDS, High Cholesterol, Embolism/Thrombosis, Hepatitis):

Please list any SKIN conditions you currently have, or have had in the past. (Example: Hypersensitive Reactions, Herpes, Melanoma, Psoriasis, Rosecea):

Please list any RESPIRATORY conditions you currently have, or have had in the past. (Example: Asthma, Chronic Cough, COPD, Emphysema, Cystic Fibrosis):

Please list any OTHER conditions you currently have, or have had in the past. (Example: Tinnitus, Kidney Stones, Diabetes, Insomnia):

Is there anything else you would like me to know?