Health History Form

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. If you have any skin allergies or skin sensitivities please contact us before your appointment and we will do our best to find a product that works for you.
Are you currently taking any medications? *
If yes, please specify on the field above.
(Prenatal Only) Are you currently pregnant? How many weeks?
*For a high risk pregnancy you will need to bring a note from your doctor that massage therapy is not contraindicated*
Recently Postpartum? How many weeks?
Do you experience tension headaches or migraines? If YES list known triggers *
If yes, please specify on the field above.
Do you currently have any symptoms of illness? Example: cough, sore throat, cold, fever, GI upset? *
If you are feeling sick you must cancel your appointment. Massage therapy is not advised if you have any symptoms of illness.
Do you have any current injuries? *
If yes, please specify on the field above.
Any current medical conditions? Specifically: Asthma, Diabetes, Heart problems, Kidney problems, High/Low Blood Pressure, Epilepsy, Scoliosis, Communicable Disease, etc.? *
If yes, please specify on the field above.
Location of any 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 *

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Should be Empty:

Health History Form

Patient Information

Emergency Contact Details

Health Data

Consent and Waiver