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Health History Form First Name:_________________________________________ Last Name:_________________________________________ Date of Birth:____________________ Address:_______________________________________________________________________ City:______________________________ E-Mail:______________________________
State:__________
Zip:_______________
Phone: (_____) ________ - _____________
1.) Have you ever had a professional massage? Y_____ N_____ 2.) Are you pregnant or trying to get pregnant? Y_____ N_____ 3.) Have you ever had any serious illnesses? Y_____ N_____ If yes please explain: Illness: ______________________________________________________ Date of Illness: ____________________ Results of Illness: ______________________________________________________ Cleared by a doctor: Y_____ N_____ 4.) Have you ever had any surgeries? Y_____ N_____ If yes please explain: Surgery: ______________________________________________________ Date of Surgery: ____________________ Results of Surgery: ______________________________________________________ Cleared by a doctor: Y_____ N_____ 5.) Are you currently on any medications? Y_____ N_____ Name of Medicine Reason for taken Medicine Last Dose _____________________ _________________________ _______________ _____________________ _________________________ _______________ _____________________ _________________________ _______________ 6.) Do you currently have any medical conditions that I should be aware of? Y_____ N_____ Condition:_________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ 7.) What do you expect from this massage?_____________________________________________________________
Therapist Signature:_________________________________________
Date:___________________
Check YES for all previous and/or current conditions (Explain if Yes) General Headaches
X
Nervous System Head Injuries/Concussions
X
Allergies Scents, Oils, Lotions
Pain
Dizziness, Ringing in Ears
Detergents
Sleep Disturbances
Loss of Memory/Confusion
Other
Infections
Numbness/Tingling
Digestive System
Fever
Sciatic, Shooting Pain
Bowel Problems
Sinus
Chronic Pain
Gas, Bloating
Other
Depression
Muscle and Joints Rheumatoid Arthritis
Other Respiratory/Cardiovascular
Bladder, Kidney, Prostate Abdominal Pain Other
Osteoarthritis
Heart Disease
Osteoporosis
Blood Clots
Thyroid
Scoliosis
Stroke
Diabetes
Broken Bones
Lymphadema
Skin Conditions
Spinal Problems
High/Low Blood Pressure
Rashes
Disk Problems
Irregular Heartbeat
Athletes Foot, Warts
Lupus
Poor Circulation
Other
TMJ, Jaw Pain
Swollen Ankles
Spasms, Cramps
Varicose Veins
Sprains, Strains
Chest Pain/Shortness of Breath
Tendonitis, Bursitis
Asthma
Stiff or Painful Joints
Contract for Care
Weak or Sore Muscles Neck, Shoulder, Arm Pain Low Back, Hip, or Leg Pain
X
Endocrine System
Additional Notes
I promise to participate fully as a member of my health care team. I will make sound choices regarding my treatment plan based on the information provided by my massage therapist and other members of my health care team, and my experience of those suggestions. I agree to participate in the self-care program we select. I promise to inform my practitioner any time I feel my well-being is threatened or compromised. I expect my massage therapist to provide safe and effective treatment.
Consent for Care It is my choice to receive massage therapy, and I give my consent to receive treatment. I have reported all health conditions that I am aware of and will inform my practitioner of any changes in my health. Signature:
Date: