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Confidential Health History
(To be completed prior to your first session)
Name
*
First
Last
Is it okay to send you text messages?
*
Yes. Texting is a great way to communicate with me.
No. Please do not text me.
Phone Number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Emergency Contact
*
First
Last
In order to plan a session that is safe and effective, I need some information. Please complete this page to the best of your knowledge.
Have you had a professional massage before?
*
Yes
No
Relationship to you
*
Emergency Contact Phone
*
Do you have any trouble lying down?
*
On your side
On your back
On your belly
If yes, explain
*
Do you have sensitive skin or allergies?
*
Yes
No
If yes, explain
*
Do you often sit or stand for long hours? Explain
*
Do you perform repetitive movements in work or daily life?
*
Yes
No
If yes, explain
*
What is your reason for coming in today? (Note areas of tension/pain, goals of session)
*
Are you currently being treated by a healthcare professional?
*
Yes
No
If yes, explain
*
Please list any medications that you are taking
*
Please check any in these 2 columns that apply to you
*
Contagious skin condition
Easy bruising
Recent fracture
Artificial joint
Current fever
Allergies/senitivities
High or low blood pressure
Vericose veins
Phlebitis
Osteoporosis
Headaches/migraines
Diabetes
Decreased sensation
Fibromyalgia
Carpal tunnel Syndrome
Joint disorder/arthritis
Comments or explanations for any of the above
*
Choose Any
*
Open wounds or sores
Recent accident/injury
Sprains/strains
Swollen glands
Heart condition
Circulatory disorders
Atherosclerosis
Deep vein thrombosis
Epilepsy
Cancer
Undiagnosed marks or growths
Back/neck problems
TMJ pain
Elbow pain
Knee pain
Shoulder pain/injury
Any chance you could be pregnant?
*
Yes
No
If yes, how many months?
*
Are there any other conditions or anything else about your health/history that you would like the practitioner to know?
*
I understand that bodywork/massage is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Check here to indicate that you have read and understood the above statements
*
I understand the above and have completed the form to the best of my knowledge
Submit
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