Name
*
Phone #
*
Format: (000) 000-0000.
Address
*
Occupation
Date of Birth
/
Month
/
Day
Year
Date
Have you received massage therapy before?
*
Yes
No
Did a health care practitioner refer you for massage therapy?
Yes
No
If yes, please provide their name and address.
Health History
Please indicate conditions you are experiencing or have experienced:
Cardiovascular
High Blood Pressure
Low Blood Pressure
Chronic Congestive Heart Failure
Heart Attack
Phlebitis/Varicose Veins/Stroke/CVA
Pacemaker Or Similar Devices
Heart Disease
Is there a family history of any of the above?
Yes
No
Respiratory
Chronic Cough
Shortness Of Breath
Bronchitis
Asthma
Emphysema
Is there a family history of any of the above?
Yes
No
Infections
Hepatitis
Skin Conditions
Bronchitis
HIV
Herpes
Loss of sensation? Where?
Diabetes, Onset?
Allergies/Hypersensitivity To What?
Type Of Reaction
Cancer, Where?
Skin Conditions, What?
Other Conditions
Epilepsy
Arthritis
Herpes
Is There A Family History Of Arthritis?
Yes
No
Head/Neck
History of headaches
History of migraines
Vision problems
Vision loss
Ear problems
Hearing loss
Pregnancy Due Date
Gynecological Conditions?
Overall How Is Your General Health?
Primary Care Physician
Address
Current Medications
What Does It Treat?
Are you currently receiving treatment from another health care professional?
Yes
No
If yes, for what?
Surgery Date And Type
Injury Date And Type
Do You Have Any Other Medical Conditions/ (e.g. digestive conditions, haemophilia, osteoporosis, mental illness)
Yes
No
If Yes Please Explain
Do You Have Any Internal Pins, Wires, Artificial Joints Or Special Equipment ?
Yes
No
If Yes, What Is It?
If Yes, Where Is It Located
What is the reason you are seeking massage therapy? Please include the location of any tissue or joint discomfort.
Date Of Initial Health History
Update 1
Update 2
Update 3
Update 4
Preview PDF
Submit
Should be Empty: