Health History Form printable pdf download

Health History

Grand River Massage Therapy Clinic

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 inform

your therapist. All information gathered for this treatment is confidential except

as required or allowed by law or except to facilitate assessment or treatment.

You will be asked to provide written authorization for releases of any information.

Today’s Date:___________________

Name:_________________________

Address:_______________________

Date Of Birth:___________________

City:_______________P.C.:________ Telephone #:____________________

Occupation:_____________________ Who referred you?:_______________

Email Address:__________________

Cell Phone #:___________________

Primary Care Physician:___________

General Health Status:

Poor Fair Good

Other Health Care:

Chiropractor

Naturopath

Physiotherapist

Emergency Contact:______________

Telephone#:____________________

Primary Complaint:_______________________________________________

How long have you had this condition?________________________________

What aggravates this condition?_____________________________________

What relieves this condition?________________________________________

Current medications and conditions treated:____________________________

_______________________________________________________________

Surgical operations? Date?________________________________________

Presence of pins, wires, artificial joints, plates?_________________________

Major accidents? Date?___________________________________________

Please indicate the areas you wish to have treated.

Health History Form