Massage Health History Form

Massage Health History Form
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Health History
Are you currently under the care of a physician?

YesNo
Please provide details
Do you have any existing medical conditions?

YesNo
Please provide details
Are you taking any medications?

YesNo
Please list medications and dosage
Have you had any surgeries in the past year?

YesNo
Please provide details
Do you have any allergies (latex, oils, lotions, etc.)?

YesNo
Please specify
Have you ever experienced any of the following conditions?

Heart problemsHigh or low blood pressureRespiratory problemsSkin conditionsNeurological disordersJoint disordersOther
Are you pregnant?

YesNo
How many weeks pregnant are you?
Do you have any specific areas of concern or areas you would like the massage therapist to focus on?
Is there anything else you think the massage therapist should know about your health?
Declaration:

I, the undersigned, confirm that the information provided in this form is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform the massage therapist of any changes in my health.
Date

MonthDayYear
Date
Signature

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Client Information