Koru Natural Health Centre
Massage Therapy Health History
Name:_____________________________________
First
Middle
File # ________
Birth Date: ________________________
Last
Address: ___________________________________
Postal Code: _______________________________
Occupation: _______________________________
MM/DD/YYYY
Telephone: ________________________________
Email: _____________________________________
Please Check any Conditions that Apply:
[ ] Headaches, type:____________________________
[ ] Limitations of Movement, where: ______________
[ ] Pain, where: _________________________________
[ ] High Blood Pressure
[ ] Phlebitis
[ ] Varicose Veins
[ ] Heart Disease
[ ] Chronic Cough
[ ] Altered Sensation (tingling, numbness)
[ ] Cancer
[ ] Menstrual Pain
[ ] Allergies
[ ] Constipation
[ ] Pregnant
[ ] Arthritis
[ ] Diabetes
[ ] Stiffness
[ ] Bruise Easily
[ ] Shortness of Breath
[ ] Contagious Skin Condition
[ ] Fatigue
[ ] Dizziness
How does this interfere with your daily routines? (i.e. work, sleep etc.) _______________________
__________________________________________________________________________________________
Surgery/Injury:____________________________________________________________________________
Date(s):__________________________________________________________________________________
Current Symptoms:_______________________________________________________________________
Current Medications and Conditions Treated:______________________________________________
__________________________________________________________________________________________
Other Medical Conditions:________________________________________________________________
Are you currently seeing any of the following practitioners for care related to this condition?
[ ] chiropractor [ ] physiotherapist [ ] occupational therapist [ ] kinesiologist [ ] other
Have you had previous massage therapy care? [ ] yes [ ] no
Rate the following on a scale (1=poor  5 =great)
Sleeping patterns: 1 2 3 4 5
Eating Habits: 1 2 3 4 5
Exercise Habits: 1 2 3 4 5
What is your goal for today’s treatment? __________________________________________________
How did you hear about our clinic? _______________________________________________________
I have filled out this for to the best of my knowledge, if there are any changes to the
above form, I will inform the therapist. I consent to be treated.
I agree to have Koru Health send me monthly newsletters and clinic notices by email.
Koru Health requires 24 hours notice of cancellation. I consent to respect this policy.
Should I provide shorter notice of cancellation, I consent to be charged a fee up to
the cost of my scheduled appointment.
Signature: __________________________________________
Date: ________________________
Primary Complaint: ______________________________________________________________________