Health History Form – Massage Therapy
Please complete this form to help us provide a safe and personalized massage experience.
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Medical Information
Are you currently under a physician's care?
*
Yes
No
If yes, please explain:
Do you take any medications we should be aware of?
*
Yes
No
If yes, please list:
Do you have any of the following conditions? (Check all that apply)
High Blood Pressure
Heart Conditions
Varicose Veins
Arthritis
Diabetes
Recent Surgery
Headaches/Migraines
Cancer (past or present)
Skin Conditions
Chronic Pain
Pregnant
Other
If other conditions, please state:
Do you have any allergies (including oils, lotions, or scents)?
*
Yes
No
If yes, please state:
Are there any areas you would like your therapist to focus on or avoid?
Focus on:
Avoid:
Consent
Type a question
*
I confirm that the above information is accurate to the best of my knowledge.
I understand that massage therapy is not a substitute for medical treatment.
I release BodyIgnite, LLC and its practitioners from liability related to any undisclosed conditions or changes in my health.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: