Updated Health History & Consent Form
Please Fill Out, Sign and Date the Entire Form & Submit for your subsequent Professional Massage Therapy Appointment
Please Review our Terms & Conditions:
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Patient Information
Name
*
First Name
Last Initial
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
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Health Information
Any Changes Since Your Last Visit
Health related questions
*
Yes
No
Remarks
Do you have a broken bone?
Do you have strains or sprains?
Are you currently using a cane or crutch?
Have you been hospitalized due to a recent injury?
Have you undergone any recent surgery?
Do you have any new allergies?
Are you taking any new medications?
Have you ceased any medications?
Do you have new dentures?
Do you have new contact lenses?
Are you experiencing new pain?
Yes
No
Do you feel recurring pain or discomfort in your body?
*
Yes
No
Where do you feel the pain?
What part of the body?
Is the pain constant, or does it get worse with movement?
What part of the body?
How do you describe the pain?
Stabbing
Aching
Burning
Numbness
Pins & Needles
Not Applicable
Other
Do you have a Referral for Massage Therapy from a Licensed Physician?
Yes
No
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What are your goals for today? (Relax, relieve tension, focus work etc)
*
Please let us know what your seeking out of treatment.
Is there anything your feel the therapist should know?
New onset of symptoms, changes in medical history, or other
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Please Review our Policies & Procedures:
Please Review our Covid-19 Consent to Treat Form:
Please Review our Client Consent to Treat Form:
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Please verify that you are human
*
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: