Health History Form
ADVERTISEMENT
1Health History Form
The information request below will assist us in treating you safely. Feel free to ask any questions about the information being requested. Please note that all information
provided below will be kept confidential unless allowed or required by law. Your written permission will be required to release any information.
________________________________________
__________________________
Name:
Phone #
______________________________________________________________________
Address:
_______________________
Occupation: ________________________________________ Date of Birth:
Yes
No
Have you received massage therapy before?
Yes
No
Did a health care practitioner refer you for massage therapy?
_____________________________________________
If yes, please provide their name and address.
_____________________________________________________________________________
Please indicate conditions you are experiencing or have experienced:
Cardiovascular
Infections
Head / Neck
high blood pressure
hepatitis
history of headaches
low blood pressure
skin conditions
history of migraines
chronic congestive heart failure
TB
vision problems
heart attack
HIV
vision loss
phlebitis / varicose veins
herpes
ear problems
stroke / CVA
hearing loss
Other Conditions
pacemaker or similar device
Women
heart disease
loss of sensation, where?
___________________
pregnant, due: ___________________
is there a family history of any of the
diabetes, onset: ________________
gynecological conditions, what?
Yes
No
above?
allergies / hypersensitivity to what?
_______________________________
_____________________________
Respiratory
type of reaction: ________________
Overall, how is your general health?
epilepsy
chronic cough
____________________________________
cancer, where?
shortness of breath
bronchitis
_____________________________
Primary Care Physician:
asthma
skin conditions, what?
____________________________________
emphysema
_____________________________
Address:
arthritis
_____________________________________
is there a family history of any of the
above? Yes No
is there a family history of arthritis?
_____________________________________
Yes
No
Do you have any other medical conditions? (e.g
Current Medications:
digestive conditions, haemophilia, osteoporosis,
mental illness) Yes
No
_________________________________________________
condition it treats: _________________________________
what? _________________________________
_________________________________________________
Do you have any internal pin, wires, artificial joints
Are you currently receiving treatment from another health care or special equipment? Yes
No
Professional? Yes No
what? __________________________________
If yes, for what? ____________________________________
where? _________________________________
Date of initial Health
__________________________________________________
History:_______________
What is the reason you are seeking massage therapy?
Update 1 ______________
Surgery – date _____________________________________
Please include the location of any tissue or joint
Update 2 ______________
nature: ___________________________________________
discomfort.
Update 3 ______________
_________________________________________
Update 4 ______________
Injury – date ______________________________________
_________________________________________
nature: ___________________________________________
_________________________________________
_______________________________________
_____________________
Signature:
Date:
PRIVACY NOTICE: Scandinave Spa Blue Mountain respects your privacy. Any personal information we collect is used
only to develop products, services and to communicate with our customers and complete transactions that ultimately
deliver our products and services to you. Your personal information is not shared, without your consent, with third
parties for the purpose of marketing or selling their products or services.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical