← Return to forms & documents Health History Form Intake form for massage therapy visits Patient Information Name * First Name Last Name Occupation What is the reason you are seeking massage therapy? * Please indicate the location of any tissue or joint discomfort. 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 information (Phone number, Address) Primary Care Physician Information (Phone number, Address) Only if different from above MEDICAL HISTORY & INFORMATION Overall, how is your general health? Are you currently receiving treatment from another health care professional? If yes, for what? Are you currently taking any medications? If yes, what & why? Have you had any? Automobile accidents Please note the date(s) and any relevant details Surgeries Please note the date(s) and any relevant details Broken Bones Please note the date(s) and any relevant details Falls/Major Injuries Please note the date(s) and any relevant details Do you have any internal pins, wires, artificial joints, or special equipment? If yes, what and where? Please check any of the following conditions you have/had: AIDS/HIV Allergies Arthritis Asthma Bronchitis Chronic Cough Cancer Chronic Fatigue Deafness Diabetes Digestion Problems Ear Problems Emphysema Epilepsy Haemophilia Headaches/Migranes Hearing Loss Heart Attack / Disease Hepatitis Herpes High Blood Pressure Low Blood Pressure Loss Of Sensation Mental Illness Osteoporosis Pacemaker Poor Circulation Sciatica Shingles Shortness Of Breath Skin Conditions Stroke Thyroid Problems TB TMJ Varicose Veins Vertigo/Dizziness Vision Problems Other: Family History of: Arthritis Cancer Diabetes Heart Problems High/Low Blood Pressure Respiratory Conditions FEMALES Are you pregnant? If yes, when are you due?: Do you have any gynaecological conditions? If yes, what? AGREEMENT By agreeing, you confirm that: * I confirm that the information I have provided in regards to my current condition and past health history are to the best of my knowledge. I also acknowledge that it is my responsibility to update the clinic in regards to any changes in my health condition. I also authorize the release of my medical condition to my family physician. Agree Disagree Thank you!We’ve received your form, see you at your appointment!
