Health History Form
ADVERTISEMENT
1HEALTH HISTORY FORM
For your information:
An accurate health history is important to ensure that it is safe for you to receive a massage treatment. If your
health status changes in the future, please let me know. All information gathered for this treatment is confidential
except as required or allowed by law or except to facilitate diagnosis (assessment) or treatment. You will be asked
to provide written authorization for release of any information.
Name:
______________________________________Date: ______________________________________
Tel: res ____________________________________
Address: _______________________________________
bus ____________________________________
_______________________________________________ Fax/email __________________________________
Date of birth: __________Occupation: ___________What is your primary complaint? ______________________
Who referred you? ________________Their address? ____________________________________________
:
Health History:
Please indicate conditions you are experiencing, or have experienced:
Respiratory
Other Conditions
Women
#
#
#
loss of sensation
pregnant (due:___________)
chronic cough
#
#
diabetes (onset: ________)
shortness of breath
#
#
Soft tissue/joint discomfort
bronchitis
allergies(ie.anaphylaxis
#
and its nature
or skin irritation
asthma
#
#
epilepsy
emphysema
#
#
neck ___________________
cancer
#
#
low back ________________
Cardiovascular
arthritis
#
mid back ________________
#
#
Head/Neck
upper back ______________
high blood pressure
#
#
shoulders _______________
low blood pressure
#
#
#
vision problems
arms ___________________
CCHF
#
#
#
vision loss
legs ____________________
heart attack
#
#
#
ear problems
knees __________________
phlebitis
#
#
#
hearing loss
other ___________________
stroke/CVA
#
pacemaker or
Infections
similar device
#
What is your general health status?
heart disease
#
hepatitis
#
_______________________________
skin conditions
Skin
#
TB
#
#
HIV
skin conditions
Current Medications: _________________________________
Primary Care Physician: ______________________________
Condition it treats: ____________________________________
Address: ___________________________________________
Surgery: _______________________________ date: ________
Present Involvement in Other Health care:
#
#
Yes
No
nature:________________________________________
If yes, please specify: ________________________________
Injury: _________________________________ date: _______
__________________________________________________
nature: ________________________________________
__________________________________________________
Other Medical Conditions (e.g. digestive conditions, gynaecological conditions, hemophilia, etc.):_________________________
_____________________________________________________________________________________________________________
Of Special Note:(presence of internal pins, wires, artificial joints, special equipment): ________________________________________
_____________________________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical