Health History Form


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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: