"Massage Therapy Health History Form"

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Health History Form
The information below will assist in treating you safely and help the Massage Therapist determine a proper treatment plan.
Feel free to ask any questions about the information being requested. Please note that all information provided will be kept
confidential unless allowed or required by law. Your written permission will be required to release any information.
Personal Information
Name:___________________________________________________
Date of Birth: (m) ________(d)__________(y)_____________
Address:_________________________________________________
City: ______________________ Postal Code: _____________
Telephone #:______________________________________________
Alt. Tel#: ___________________________________________
Email:____________________________________________________
Occupation: ________________________________________
Have you ever 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:_________________________________________________________________________
Name and Address of Primary Care Physician:________________________________________________________________________
How did you hear about me:________________________________________________________________________________________
Medical Information
***It is important that you complete this portion as accurately as possible***
Cardiovascular
Infections
Head/Neck
High Blood Pressure
Hepatitis
History of headaches/migraines
Low Blood Pressure
Skin Conditions
Vision Problems
CCHF
TB
Vision Loss
Heart Attack
HIV
Ear Problems
Phlebitis/varicose veins
Herpes
Hearing Loss
Stroke/CVA
Pacemaker or similar device
Other Conditions
Women
Heart Disease
Loss of Sensation, Where?
Pregnant Due:__________________
Is there a family history of any
______________________
Gynaecological Conditions
of the above? Y N
Diabetes, Onset:_________
What?_________________________
What?__________________
Allergies/Hypersensitivity
Breast Pain
What?_________________
Other:__________________________
Respiratory
Type of Reaction:________
Chronic Cough
Epilepsy
Soft Tissue/Joint Pain
Shortness of Breath
Cancer, Where?__________
Neck
Bronchitis
Skin Conditions
Upper Back/Shoulders
Asthma
What and Where?________
Arms/Hands
Emphysema
_______________________
Mid Back
Is there a family history of any
Arthritis
Low Back
of the above? Y N
Is there a family history of any
Hips/Buttocks
Which?__________________
of the above? Y N
Legs/Knees/Feet
Which?___________________
Do you have any other medical conditions? (e.g. digestive conditions, haemophilia, osteoporosis, mental illness)
__________________________________________________________________________________________________________
Do you have internal pins, wires, artificial joints, or special equipment? If so, where?
__________________________________________________________________________________________________________
Current Medications:
Condition it treats:
_______________________________________
________________________________________________________
_______________________________________
________________________________________________________
Previous injury/surgery:
Date of injury/surgery:
_______________________________________
________________________________________________________
_______________________________________
________________________________________________________
Health History Form
The information below will assist in treating you safely and help the Massage Therapist determine a proper treatment plan.
Feel free to ask any questions about the information being requested. Please note that all information provided will be kept
confidential unless allowed or required by law. Your written permission will be required to release any information.
Personal Information
Name:___________________________________________________
Date of Birth: (m) ________(d)__________(y)_____________
Address:_________________________________________________
City: ______________________ Postal Code: _____________
Telephone #:______________________________________________
Alt. Tel#: ___________________________________________
Email:____________________________________________________
Occupation: ________________________________________
Have you ever 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:_________________________________________________________________________
Name and Address of Primary Care Physician:________________________________________________________________________
How did you hear about me:________________________________________________________________________________________
Medical Information
***It is important that you complete this portion as accurately as possible***
Cardiovascular
Infections
Head/Neck
High Blood Pressure
Hepatitis
History of headaches/migraines
Low Blood Pressure
Skin Conditions
Vision Problems
CCHF
TB
Vision Loss
Heart Attack
HIV
Ear Problems
Phlebitis/varicose veins
Herpes
Hearing Loss
Stroke/CVA
Pacemaker or similar device
Other Conditions
Women
Heart Disease
Loss of Sensation, Where?
Pregnant Due:__________________
Is there a family history of any
______________________
Gynaecological Conditions
of the above? Y N
Diabetes, Onset:_________
What?_________________________
What?__________________
Allergies/Hypersensitivity
Breast Pain
What?_________________
Other:__________________________
Respiratory
Type of Reaction:________
Chronic Cough
Epilepsy
Soft Tissue/Joint Pain
Shortness of Breath
Cancer, Where?__________
Neck
Bronchitis
Skin Conditions
Upper Back/Shoulders
Asthma
What and Where?________
Arms/Hands
Emphysema
_______________________
Mid Back
Is there a family history of any
Arthritis
Low Back
of the above? Y N
Is there a family history of any
Hips/Buttocks
Which?__________________
of the above? Y N
Legs/Knees/Feet
Which?___________________
Do you have any other medical conditions? (e.g. digestive conditions, haemophilia, osteoporosis, mental illness)
__________________________________________________________________________________________________________
Do you have internal pins, wires, artificial joints, or special equipment? If so, where?
__________________________________________________________________________________________________________
Current Medications:
Condition it treats:
_______________________________________
________________________________________________________
_______________________________________
________________________________________________________
Previous injury/surgery:
Date of injury/surgery:
_______________________________________
________________________________________________________
_______________________________________
________________________________________________________
Please Circle your areas of complaint
on the diagram provided below:
Please mark on the line below the level of your discomfort.
____________________________________________________
0
5
10
No Pain
Moderate
Worst Pain
Is this pain/discomfort the result of an injury or car accident? If yes,
please provide details:__________________________________________
______________________________________________________________
Have you seen your physician (or other doctor) for this issue? Y N
Diagnosis?____________________________________________________
Does this interfere with your work or daily activities? Y N
Are you currently receiving treatment from another health care
professional? Y N What and who?_____________________________
Is there anything else you would like your massage therapist to
know?________________________________________________________
What is your primary concern (reason for seeking Massage Therapy)?
______________________________________________________________
Overall, how is your general health?_____________________________
Policy and Fee Schedule
Appointments: Massage Therapy sessions are booked by appointment only. Please provide 24 hours for any cancellations.
Payment: Payment is expected in full for each visit. Payments methods include cash, cheque, Interac (debit), VISA and Mastercard.
Fees:
30 minutes - $60
45 minutes - $80
60 minutes - $92
90 minutes - $130
In compliance with the “Personal Health Information Protection Act”, written consent is required before any information can be
released to a third party (ie. Insurance company). There may be a fee to obtain a copy of your files upon written request.
I understand that Registered Massage Therapists do not diagnose illness, disease or any mental or physical disorder. I have stated
all medical conditions that I am aware of and will update the Massage Therapist of any changes in my health status.
Signature:__________________________________________________________________
Date:_______________________________
Clinic Use Only: Updates Required Annually
Date of Initial Health History:________________________
Date of update:_____________________________________
Details:____________________________________________
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