Health History Form

The information request below will assist us in treating you safely. Feel free to ask any questions about the information being requested.
Please note that all information provided below will be kept confidentially unless allowed or required by law. Your written permission will
be required to release any information.

Name: ______________________________________________ Phone # _______________________

Address:____________________________________________________________________________
Occupation:__________________________________________ Date of Birth: ___________________
Have you received massage therapy before? Yes No
Did a health care practitioner refer you for massage therapy? Yes No
If yes, please provide their name and address. _______________________________________________
__________________________________________________________________________________

Please indicate conditions you are experiencing or have experienced:

Cardiovascular Infections Head/Neck
high blood pressure hepatitis history of headaches
low blood pressure skin conditions history of migraines
chronic congestive heart failure TB vision problems
heart attack HIV vision loss
phlebitis / varicose veins herpes ear problems
stroke/CVA hearing loss
pacemaker or similar device Other Conditions
heart disease loss of sensation, where? Women
_________________ pregnant, due:________________
is there a family history of any of the diabetes, onset: _____________ gynaecological conditions,
above? Yes No allergies/hypersensitivity to what?______________________
what?
Respiratory __________________________ Overall, how is your general health?
chronic cough type of reaction: _____________ _______________________________
shortness of breath epilepsy
bronchitis cancer, where? Primary Care Physician:
asthma ____________________ ___________________________
emphysema skin conditions, what? Address:
__________________ ___________________________
is there a family history of any of the arthritis
above? Yes No
is there a family history of arthritis? ___________________________
Yes No
Current Medications: Do you have any other medical conditions? (e.g.
___________________________________________ digestive conditions, haemophilia, osteoporosis, mental
condition it treats: ____________________________ illness) Yes No
___________________________________________ what? _______________________________________

Are you currently receiving treatment from another health care Do you have any internal pins, wires, artificial joints or
professional? Yes No special equipment ? Yes No
If yes, for what? _________________________________ what? ______________________________________
______________________________________________ where? _____________________________________

Surgery date ____________________________ What is the reason you are seeking massage therapy?
nature: __________________________________ Please include the location of any tissue or joint
discomfort.
Injury date ______________________________ ____________________________________________
nature: __________________________________ ____________________________________________
____________________________________________
Notes:
Date of initial Health
History:_____________
Update 1 ___________
Update 2 ___________
Update 3 ___________
Update 4 ___________