Health History Form
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1Health History Form
The information request below will assist us in treating you safely. Feel free to ask any questions about the information being requested.
Please note that all information provided below will be kept confidentially unless allowed or required by law. Your written permission will
be required to release any information.
Name: ______________________________________________ Phone # _______________________
Address:____________________________________________________________________________
Occupation:__________________________________________ Date of Birth: ___________________
Have you received massage therapy before?
Yes
No
Did a health care practitioner refer you for massage therapy?
Yes
No
If yes, please provide their name and address. _______________________________________________
__________________________________________________________________________________
Please indicate conditions you are experiencing or have experienced:
Cardiovascular
Infections
Head/Neck
high blood pressure
hepatitis
history of headaches
low blood pressure
skin conditions
history of migraines
chronic congestive heart failure
TB
vision problems
heart attack
HIV
vision loss
phlebitis / varicose veins
herpes
ear problems
stroke/CVA
hearing loss
pacemaker or similar device
Other Conditions
loss of sensation, where?
Women
heart disease
_________________
pregnant, due:________________
diabetes, onset: _____________
gynaecological conditions,
is there a family history of any of the
allergies/hypersensitivity to
what?______________________
above?
Yes
No
what?
__________________________
Overall, how is your general health?
Respiratory
type of reaction: _____________
chronic cough
_______________________________
epilepsy
shortness of breath
cancer, where?
bronchitis
Primary Care Physician:
____________________
asthma
___________________________
skin conditions, what?
emphysema
Address:
__________________
___________________________
arthritis
is there a family history of any of the
above?
Yes
No
___________________________
is there a family history of arthritis?
Yes
No
Current Medications:
Do you have any other medical conditions? (e.g.
___________________________________________
digestive conditions, haemophilia, osteoporosis, mental
illness)
Yes
No
condition it treats: ____________________________
what? _______________________________________
___________________________________________
Do you have any internal pins, wires, artificial joints or
Are you currently receiving treatment from another health care
special equipment ?
Yes
No
professional?
Yes
No
what? ______________________________________
If yes, for what? _________________________________
where? _____________________________________
______________________________________________
What is the reason you are seeking massage therapy?
Surgery – date ____________________________
Please include the location of any tissue or joint
nature: __________________________________
discomfort.
____________________________________________
Injury – date ______________________________
____________________________________________
nature: __________________________________
____________________________________________
Notes:
Date of initial Health
History:_____________
Update 1 ___________
Update 2 ___________
Update 3 ___________
Update 4 ___________
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Parent category: Medical