Confidential Patient Case History Form Page 2
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1
2Do you have any medical conditions not listed above?
Yes
No
If yes, please describe: ________________________________________________________________________
Do you have any internal wires, artificial joints, pacemakers or special equipment that we should be aware
of?
Yes
No
___________________________________________________________________________________________
Please circle areas which are currently causing you symptoms of pain, stiffness, numbness or other forms
of discomfort
Face
Upper back
Arm(s)
Hand(s)
Thigh(s)
Ankle(s)
Neck
Mid back
Elbow(s)
Finger(s)
Knee(s)
Feet
Shoulder(s)
Lower back
Wrist(s)
Hip(s)
Leg(s)
Toe(s)
Chest
Ribs
Tailbone
For what condition or reason are you seeking treatment today? ____________________________________
___________________________________________________________________________________________
Have you seen any other health care professional(s) for this condition or reason?
Yes
No
If yes whom? ________________________________________________________
Have you ever been involved in any motor vehicle accidents?
Yes
No Date:___________________
Have you been involved in any other accidents?
Yes
No Date:___________________
Have you ever been knocked unconscious?
Yes
No Date:___________________
Briefly list any surgeries you have undergone, for what and when.
___________________________________________________________________________________________
___________________________________________________________________________________________
Are you presently taking any prescribed medication(s)?
Yes
No
If yes, please list the medication(s) and the condition(s) for which it is being used if known.
___________________________________________________________________________________________
___________________________________________________________________________________________
Have you previously received massage therapy treatments?
Yes
No
If yes, were you treated:
At this clinic
From an RMT
Other
Please circle on the following scales the extent to which you are currently satisfied with the following:
(
)
5 represents total satisfaction, 1 represents little or no satisfaction
Physical health & fitness
5
4
3
2
1
Mental & emotional happiness
5
4
3
2
1
Energy level
5
4
3
2
1
Diet
5
4
3
2
1
Ability to relax
5
4
3
2
1
I acknowledge that the Massage Therapist is not a physician and does not diagnose illness or disease or any other
physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It
is recommended that I attend my personal physician for any ailment that I may be experiencing. I acknowledge that no
assurance or guarantee has been provided to me as to the results of the treatment.
I acknowledge and understand that the Massage Therapist must be fully aware of my existing medical conditions. I
have completed my medical history form as provided by my Massage Therapist and disclosed all of those medical
conditions affecting me. It is my responsibility to keep the Massage Therapist updated on my medical history. The
information I have provided is true and complete to the best of my knowledge.
_____________________________________________
____________________
________________________
Signature
Date
Therapist Signature
_____________________________________________
____________________
________________________
Signature
Date
Therapist Signature
_____________________________________________
____________________
________________________
Signature
Date
Therapist Signature
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