Health History Form
ADVERTISEMENT
1
2Health History Form
FYI: 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 us know. All information gathered on this form is
confidential. Your written authorization is legally required before any of this information can be released.
Personal Information
Name: ____________________________________________________ Date: ___________________
Address: __________________________________ City: ________________ Postal Code: ________
Home Phone: __________________ Work Phone: ________________ Occupation: ______________
Date of Birth: __________________ Email: _______________________ Height: _____ Weight:_____
Doctor: _________________________________ Phone: ______________ May I contact? ¨Yes ¨No
Emergency Contact Name: ______________________________ Phone: _______________________
Have you had a massage before? ¨Yes ¨No For relaxation or other reason?: ______________________________
Current Medications: __________________________________________________________________________
Previous Major Illnesses, Operations: _____________________________________________________________
Accidents (please give dates): ___________________________________________________________________
___________________________________________________________________________________________
Other Medical Conditions (e.g. hemophilia, diabetes): _________________________________________________
Family history (major illnesses, operations): _________________________________________________________
Please indicate all conditions you have experienced. Mark C for current or P for past.
Joint/Soft Tissue Discomfort:
General Symptoms:
Infectious:
__ Arms
__ Fainting
__ Hepatitis
__ Upper Back
__ Dizziness
__ Tuberculosis
__ Mid Back
__ Loss of Sleep
__ Human Immunodeficiency Virus (HIV)
__ Lower Back
__ Fatigue
__ Herpes
__ Degenerative Discs
__ Nervousness
__ Cold
__ Feet
__ Sudden Weight Loss/Gain
__ Flu
__ Athlete’s Foot
__ Hands
__ Numbness
__ Hips
__ Tingling
__ Warts
__ Jaw
__ Paralysis
Other ____________________________
__ Knees
__ Headaches (Tension)
Digestive:
__ Legs
__ Migraines
__ Poor Appetite
__ Neck
__ Belching/Gas
__ Osteo Arthritis
__ Constipation
Cardiovascular:
__ Rheumatoid Arthritis
__ Diarrhea
__ High Blood Pressure
__ Sciatica
__ Nausea
__ Low Blood Pressure
__ Shoulders
__ Ulcer
__ Coronary Heart Disease
__ Limitation of Movement
__ Vomiting
__ Heart Attack
in which joints: _________________
Eye, Ear, Nose, Throat:
__ Phlebitis
Other _________________________
__ Stroke / CVA
__ Allergies
Skin:
__ Pacemaker
__ Frequent Colds
__Rashes
__ Heart Murmur
__ Glasses or Contacts
__Itching
__ Palpitations
__ Hearing Aid
__Bruise Easily
__ Varicose Veins
__ Hearing Loss
__Dryness
__ Swelling of the Ankles
__ Sinus Infection
__Boils
__ Poor Circulation
__ Swollen Glands
Other _________________________
(continued on reverse)
HHMCA-06/08
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical