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
*
Submit
Should be Empty: