Health History Form Page 2
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1
2Please indicate all current and past conditions you have experienced.
Head/Neck
Current
Past
Respiratory/Lungs
Current
Past
Digestive
Current
Past
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Whiplash
Asthma
Constipation
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Headache
Bronchitis
Diarrhea
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Crohn’s
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Migraine
Emphysema
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Concussion
Pneumonia
I.B.S
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Ring in ears
Short of breath
Ulcers
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Hearing Loss
Sinusitis
Diverticulitis
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Vision Problems
Frequent Colds
Nausea
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Brain Injury
Recurrent lung infection
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TMJ (Jaw Pain)
Chronic Cough
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Other:_________
Other:______________
Other:______
Cardiovascular
Current
Past
Nervous System
Current
Past
Infections
Current
Past
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High B.P. __/__
Spinal Cord Injury
Hepatitis
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Low B.P. __/__
Numbness/Tingling
Type____
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Heart Attack
Sensory Change/Loss
Skin
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C.C.H.F
Sciatica
Conditions
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Chest pain/angina
Thoracic Outlet (TOS)
TB
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Stroke
Seizures
HIV
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Pace Maker
Multiple Sclerosis
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Phlebitis
Cerebral Palsy
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Hemophilia
Epilepsy
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Heart Disease
Carpal Tunnel
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Blood Clot
Muscular Dystrophy
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Other:__________
Other:______________
Other:______
Disease/Condition
Current
Past
Skin Conditions
Current
Past
Bone/Joint
Current
Past
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Cancer
Eczema
Dislocation
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Type/Location____
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Dermatitis
Fracture
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Treatment_______
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Acne
Arthritis
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Fibromyalgia
Frost Bite
DDD
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Chronic Fatigue
Psoriasis
Herniated Disc
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Allergies
Sensitive Skin
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Diabetes (Type__)
Rash/Eruptions
Family History
Yes
No
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Onset:__________
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Cold Sores
Of Arthritis?
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Herpes
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Other:__________
Other:______________
Other:_______
Soft Tissue/Joint
Current
Past
Soft Tissue/Joint
Women Only
Current
Past
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Neck
Feet
Pregnancy
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Shoulder
Tendonitis
Vaginal Birth
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Arm
Swelling
# of weeks___
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Wrist/Hand
Strain/Sprain
# of kids_____
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Back
Restricted Movement
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Hips
Poor Posture
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Legs
Other:_______
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Knees
Other:______________
□Yes
□No
□Yes
□No
□Yes
□No
Physically Active?
Previous Massage?
Good Sleep?
□Yes
□No
Good Eating Habits
Date:____________
Client Signature:_________________ Therapist Signature:__________
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