THERAPEUTIC MASSAGE REGISTRATION AND HISTORY
Patient Information
Gender □ M □ F
Date ____________________________
Patient Name_____________________________________
Last
First
Age __________
Birthdate _________________________
MI
□ Married
Address_________________________________________
□ Single □ Other
Occupation______________________________________
City _________________________________
Employer/School_________________________________
State ______________ Zip ______________
Whom may we thank for your referral?
E-mail __________________________________________
_______________________________________________
Home Phone (_____)___________________
Mobile Phone (______)_____________________
IN CASE OF EMERGENCY, CONTACT
Work Phone (______)_____________________
Communication Preference (circle one)
Name__________________________________________
Phone:
Phone (______)_________________
Cell
Relationship_____________________________________
Home
Can we contact you via email:
Yes
Preference on appointment reminder:
No
Email
Home
Cell
Do Not Contact
Reason for visit __________________________________________________________________
When did your symptoms appear? ____________________________________________
Is this condition getting progressively worse?
□ yes
□ no
□unknown
Mark an X, on the picture to the left, where you continue to have pain, numbness and/or
tingling.
Rate the severity of the pain on a scale from 1 (least) to 10 (severe)___________________
Type of pain :
□ burning
□ sharp
□ tingling
□ dull
□ throbbing
□ cramps
□ stiffness
□ numbness
□ swelling
□ aching
□ shooting
□ other
How often do you have this pain? ________________________________________________
Is it constant or does it come and go?_____________________________________________
Does it interfere with:
□ work
□ sleep
□ daily routine
□ recreation
Health History
Injuries/Surgeries you’ve had
Description
Date
Falls ____________________________________________________________________________________________________________
Head Injuries_____________________________________________________________________________________________________
Broken Bones ____________________________________________________________________________________________________
Dislocation _______________________________________________________________________________________________________
Surgeries ________________________________________________________________________________________________________
Medications
Allergies
Vitamins/Herbs/Minerals
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
What treatments have you already received for your condition?
□ medication
□ surgery
□ physical therapy
□ massage
□ acupuncture
□ chiropractic
□ other
Please check if you have had any of the following :
□ AIDS/HIV
□ Constipation
□ Heart Disease
□ Parkinson’s Disease
□ Alcoholism
□ Deep Vein Thrombosis
□ Hepatitis
□ Pinched Nerve
□ Allergies
□ Depression
□ Hernia
□ Polio
□ Anemia
□ Diabetes
□ Herniated Disk
□ Rashes
□ Arthritis
□ Dizziness
□ High Blood Pressure
□ Sciatica
□ Asthma
□ Edema
□ Indigestion
□ Scoliosis
□ Athlete’s Foot
□ Emphysema
□ Kidney Disease
□ Shortness of Breath
□ Bleeding Disorders
□ Epilepsy
□ Liver Disease
□ Stroke
□ Blood Clots
□ Fainting
□ Low Blood Pressure
□ Tendinitis
□ Breast Lump
□ Fatigue (chronic)
□ Migraine Headaches
□ Thyroid Problems
□ Bursitis
□ Fibromyalgia
□ Miscarriage
□ TMJ Dysfunction
□ Cancer
□ Goiter
□ Multiple Sclerosis
□ Varicose Veins
□ Chemical Dependency
□ Gout
□ Osteoporosis
□ Warts
□ Cold Hands/ Feet
□ Headaches
□ Pacemaker
EXERCISE
WORK ACTIVITY
HABITS
□ none
□ sitting
□ smoking
packs/day______________
□ moderate
□ standing
□ alcohol
drinks/week ____________
□ daily
□ light labor
□ caffeine
cups/day_______________
□ heavy
□ heavy labor
□ high stress
reason ________________
Are you pregnant?
□ yes
□ no due date ________________________________
PLEASE READ THIS STATEMENT & SIGN BELOW
I have stated all of my conditions that I am aware of. This information is true and accurate. I understand that massage
therapy is not a substitute for medical care that may be needed for conditions listed on the registration and history form. If
any condition I have now is contraindicated to massage therapy, the therapist has a right to refuse treatment. I agree to
keep the practitioner informed and updated of any medical changes that may occur and I understand that there will be no
liability on the practitioner or Division Chiropractic and Acupuncture’s part if I fail to do so. If any sexually suggestive
remarks take place from the client during the session, immediate termination of the session is a result and I will be liable
for payment of service in full.
______________________________
(client signature)
________________________
(date)