Health History Form

Health History Form
General Patient Information
Client Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Client E-Mail
example@example.com
Client Birth Date

MonthDayYear
Client Medical History
Do you currently or have you ever had (Please check all that apply)
If you checked any options above, please explain any details that may affect your session:
Do you have any health problems not listed above that may affect your session?
Are you currently being treated by a physician, massage therapist, chiropractor, etc for any condition?
Are you currently taking any medication that may affect your session?
Physical Health Habits
Occupational activity level:
Is your occupation contributing to physical pain?
Are you currently following a structured exercise plan? If yes, please explain.
Do you stretch on your own regularly? If yes, how often?
What would you most like to receive from your FST session?
The above information is accurate and true to the best of my knowledge. If there are any changes in my current level of health, I will inform the practitioner of my condition. I understand that this practitioner does not diagnose or treat illness or disease and does not prescribe medications.

I acknowledge that I am aware of the risks involved and give consent to receive Fascia Stretch Therapy from this practitioner. It is agreed that any claim of liability is hereby waived.
Signature
Should be Empty:

Client Medical History