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 Name
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 using a cane or crutch?
Have you been hospitalized due to a recent injury?
Have you undergone any recent surgery?
Do you have any allergies?
Are you taking any new medications?
Have you ceased any medications?
Do you have new dentures?
Do you have new contact lenses?
Do you feel any pain or discomfort in your body?
*
Yes
No
Where do you feel the pain? (Type N/A if not applicable)
*
What part of the body?
It the pain consistent or does it get worse with movement? (Type N/A if not applicable)
*
What part of the body?
How do you describe the pain?
*
Stabbing
Aching
Burning
Numbness
Pins & Needles
Not Applicable
Other
Have you spoken with a doctor if you are experiencing new issues?
*
Yes
No
If you have spoken with a doctor, do you have a Referral for Massage Therapy?
*
Yes
No
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What are your goals for today? (Relax, relieve tension, focus work etc)
Is there anything your feel the therapist should know?
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Please Review our Policies & Procedures:
Please Review our Covid-19 Consent to Treat Form:
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Please Review our Client Consent to Treat Form:
Do you agree with our Client / Therapist Agreement & Consent to Treat?
*
Yes
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Please verify that you are human
*
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: