Health History Form s4

Health History Form

An accurate health history ensures that it is safe for you to receive massage therapy and helps the therapist determine the best possible way to address your needs during the session. All answers to these questions will remain confidential. We appreciate you taking the time to complete this questionnaire. Thank you.

Personal Information (Please print) Name: ______Address: ______City: ______Postal Code: ______Daytime Phone: ______Evening Phone: ______Birth Date: ______Email: ______Emergency Contact Name: ______Phone: ______

Have you had a massage before? Yes No Current Medications: ______Previous Major Illnesses, Operations: ______Accidents (please give dates): ______Other Medical Conditions (ie: diabetes, hemophilia): ______

Please specify allergies: ______Many of our products contain nut oils or milk products; we can make accommodations if you require them. The massage menu outlines the types of oils and additives used. Please also indicate if there are any essential oils you are allergic to.

Please indicate all conditions you have experienced. Mark C for current or P for past:

Joint/Soft Tissue ___ Legs Skin: Discomfort: ___ Neck ___ Rashes ___ Arms ___ Shoulders ___ Itching ___ Upper Back ___ Osteo-Arthritis ___ Bruise Easily ___ Middle Back ___ Rheumatoid ___ Dryness ___ Lower Back Arthritis ___ Boils ___ Degenerative Discs ___ Sciatica ___ Feet ___ Limitation of General Symptoms: ___ Hands Movement ___ Fainting ___ Hips In which joint(s)? ___ Dizziness ___ Jaw ______Knees ______(Continued on Reverse) Health History

General Symptoms ___ Heart murmur ___ Chronic Cough (continued): ___ Palpitations ___ Bronchitis ___ Sudden Weight ___ Varicose Veins ___ Asthma Loss/Gain ___ Swelling of Ankles ___ Difficulty Breathing ___ Numbness ___ Poor Circulation ___ Smoking ___ Tingling ___ Emphysema ___ Paralysis Infectious: ___ Pneumonia ___ Headaches ___ Hepatitis (tension) ___ Tuberculosis Digestive: ___ Migraines ___ Athlete’s Foot ___ Constipation Other: ______Nausea Cardiovascular: ___ Ulcer ___ High Blood Pressure Eye, Ear, Nose, Throat: ___ Low Blood Pressure ___ Frequent Colds Reproductive: ___ Heart Disease ___ Hearing Loss ___ Pregnant ___ Heart Attack ___ Sinus Infection Due Date: ______Phlebitis ___ Stroke / CVA Respiratory: ______

Please specify any areas of concern that you would like the massage therapist to address during the session: ______If you are feeling discomfort in the areas specified (above), please indicate how long you’ve had these symptoms: ______If applicable, what aggravates your condition? ______Is there anything that you have done that provided some relief: ______

Please indicate areas where you are experiencing discomfort by drawing an X on the diagrams below:

By signing below you are acknowledging that the information you have provided is true and accurate. Please keep in mind that you are required to inform the massage therapist of any changes in health status before your next appointment.

______Signature of client or legal guardian Today’s date