Health History Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Health Data
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.
Are you pregnant? How many weeks? (Female Only)
If yes, please specify on the field above.
Postpartum? How many weeks? (Female Only)
Postpartum is the 12 week period after giving birth
Do you experience tension headaches or migraines? If YES list known triggers
If yes, please specify on the field above.
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
What are your goals for this treatment session?
If yes, please specify on the field above.
How did you hear about us?
Do you have a gift certificate? Who were you referred by?
Consent and Waiver
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, allergies and injuries.
I agree to inform the therapist of any changes in my health and medical condition.
Signature
Clear
Submit
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