signature
Date of initial health history:
Update 1
Update 2
Update 3
Update 4
Health history form
For your information; an accurate health history is important to ensure that it is safe for you to receive a massage
treatment. If your health status changes in the future, please let us know. All information gathered for this treatment are
confidential. You will be asked to provide written authorization for release of any information.
Today’s date:
First name:
Birth date m/d/y:
Gender: Street address:
M:
Postal code:
F:
PATIENT INFORMATION
Last name:
Home phone no.:
City:
Email:
Occupation:
Name and address of your physician:
Who referred you?
What is the reason you are seeking massage therapy today:
Have you had previous treatment for the above complaint by a massage therapist
Chiropractor:
Physiotherapist:
MD:
Please check conditions experienced now and in the past
Current:
Other:
Previous:
Muscle strain/ligament sprain
Tendonitis/ fibrositis/bursitis
Muscle strain/ligament sprain
Tendonitis/ fibrositis/bursitis
Fracture, location:
Fracture, location:
Whiplash, when?
Whiplash, when?
Other, specify:
Other, specify:/
Any additional information you would like to provide?
Have you taken any anti-inflammatory medication, pain killers, muscle relaxants or mood alternating medication
within the past two hours?
If yes, details please:
Are you on any medication(s) right now?
If yes, details please:
Other medical conditions (digestive, gynecological, hemophilia, etc …)?
Are you allergic to nuts, oils or cream?
If yes, please details:
Presence of internal pins, wires, artificial joints, special equipment:
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PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING CONDITION
HEAD/NECK
RESPIRATORY
Headache
Asthma
Migraine
Chronic cough
Migraine with aura
Shortness of breath
Vision problems
Bronchitis
Contact lenses
emphysema
Earaches
SKIN
DIGESTIVE/URINARY
Skin conditions
Type:
Difficult digestion
Bruise easily
Constipation
Plantar warts
Liver/gall bladder
Rashes
Kidney/bladder
Loss of sensation
Where?
Crone’s disease/ colitis
Eczema/psoriasis
Where?
Diabetes, onset
ulcers
CARDIOVASCULAR
MUSCLE/JOINTS
High blood pressure
Neck
Low blood pressure
Low back
Poor circulation
Mid-back
Heart disease
Upper back
Shortness of breath
Shoulders
Phlebitis
Hip
Varicose veins
Knee
Chronic congestive heart
Ankle
Failure
Other:
stroke
Myocardial infraction
Pacemaker
OTHER CONDITIONS
FEMALE
Hemophilia
Menstrual problem
Epilepsy
Painful:
Heavy:
Scant:
Frequent colds
Pregnancy-due
Date:
Cancer
Date of last check up:
Menopausal problem
Type:
arthritis
RA:
OA:
Other:
SURGICAL IMPLANTS
Fibromyalgia
Pins
Osteoporosis
Wires
Chronic fatigue syndrome
Artificial joints/limbs
Polio, post polio syndrome
Other:
Scoliosis
Carpal tunnel syndrome
INFECTIOUS CONDITIONS
Tuberculosis
AIDS/HIV
Hepatitis
Type:
Infectious skin
Location:
condition(s)
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