Health History Form And Consent
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1
2Stephanie Faucher, RMT
Health History Form and consent
An accurate health history ensures that it is safe for you to receive a massage treatment, and helps the therapist determine a proper treatment plan.
When your health status changes in the future, please let me know. All information gathered on this form is confidential. Your writte n authorization is
legally required before any of this information can be released.
Name:_________________________________________Phone #:________________________________
Address:________________________________________ Postal Code:____________________________
Occupation: ____________________________________Date of Birth:_______________ Age:__________
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.____________________________________________________
_____________________________________________________________________________________
Doctor's name:_________________Address:_________________________________Phone #:___________
Do you see other healthcare practitioners?______________________________________________________
Current Medications_____________________________________________________________________
Allergies/Hypersensitivities________________________________________________________________
Family history of________________________________________________________________________
Major Accidents (include dates)_____________________________________________________________
Other serious Medical Conditions___________________________________________________________
Injury/Surgery_________________________________________________________________________
Health Plan? Yes
No
_______________________________________________________________
Please indicate areas you would like me to focus on and your primary area of complaint.
What is your primary complaint?
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Office use only
Date of initial heath history:
Notes:
update 1____________
update 2______________
update 3______________
update 4______________
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Parent category: Medical