Health History Form
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1
2Health History Form
Updated:
Date:
Initial:
For Your Information:
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An accurate health history is important to ensure that it is safe for you to receive a massage
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therapy treatment. If your health status changes, let your massage therapist know as soon
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as possible and this form will be updated. All information gathered for this treatment is
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confidential, and will only be used to facilitate a diagnosis (assessment), and treatment.
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You will be asked to provide written authorization for release of any information.
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Personal Data:
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Today’s Date: ____________________
Name: _________________________________
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Street Address: __________________________
Phone# (Home): __________________
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City: ___________________________________
(Cell): ____________________
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Postal Code: ____________________________
(Work): ___________________
Date of Birth(mm/dd/yyyy):________________
Occupation: ______________________
Primary Care Physician: ___________________
Emergency Contact :_______________
Physician’s Address:______________________
Phone #: _________________________
Email Address: _________________________________________________________________
Who Referred you?: _____________________________________________________________
Treatment Information:
What is your primary complaint? ___________________________________________________
Do you experience headaches?
Yes
No
If yes, frequency: __________________
Do you experience migraines?
Yes
No
If yes, frequency: ________________________
Do you have a headache/migraine at the moment?
Yes
No
Have you ever received a professional massage?
Yes
No
What is your general health status? _________________________________________________
Health History:
Current Medications: ____________________________________________________________
Condition it treats: ______________________________________________________________
Are you presently involved in any other health care?
Yes
No
If yes, please specify the type: _____________________________________________________
Have you ever had surgery?
Yes
No
If yes, dates of surgery? ___________________
Please identify the nature of the surgery: _____________________________________________
Please list any significant injuries: ____________________ Date of injury: _________________
Have you ever been in a car accident? Yes or No If yes, date and injuries:__________________
Other Medical Conditions: (e.g. digestive, gynecological, etc.)
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Of special note: (presence of internal pins, wires, artificial joints, special equipment)
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Please indicate the following:
Circle areas of pain (0)
Mark an (X) over areas of stiffness/tension
Draw lines (///) over areas of numbness/tingling
SEE PAGE 2
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Parent category: Medical