Grand Wellness Centre



202 Grand River Avenue Suite A
BRANTFORD Ontario N3T 4X9
Tel: (519)759-1311   Email: grandwellnesscentre@gmail.com

Health History Form


Before proceeding with a massage therapy appointment, your therapist will need to review your health history in order to ensure that your treatments are safe and beneficial. To save time on your first appointment, complete this form in full. If you elect not to complete the form before you arrive, your therapist will require that you complete it at the beginning of your appointment.


Client Information


First Name:
Last Name:
Birth Date:
Home Phone:
Email:
Street Address:
City:
Province / State:
Postal / ZIP Code:
Country:
Occupation:
Prior history of massage?
Gender:
YYYY/MM/DD
 Female  Male
YYYY/MM/DD

For each of the following sections, please check any items that apply to you.


If a textbox is provided instead of a checkbox, use the space to type any relevant information that may apply.


Cardiovascular Issues


The following items relate to circulation and the heart.


Respiratory Issues


The following items relate to breathing and the lungs.


Infections


The following items relate to bacterial and viral infections.


Head and Neck Issues


The following items relate to conditions of the head and senses.


Women's Issues


The following items relate to female specific conditions.


YYYY/MM/DD

Other Conditions


The following items relate to other relevant conditions which may impact treatment.


Current and Prior Healthcare


The following items relate to previous medical care you may have received.


Please list any medications you may be taking and any potential side effects. To add a medication, use the Add New Medication button.


Current Medications     


Name

Side Effects

Please list any injuries you have endured, from birth until the current day. To add an injury, use the Add New Injury button.


Previous Injuries      


Type

Body Region

Date (YYYY/MM/DD)

Please list any surgeries you have undergone, from birth until the current day. To add a surgery, use the Add New Surgery button.


Previous Surgeries      


Type

Body Region

Date (YYYY/MM/DD)

Is there any other relevant information, concern or diagnosis?




When you have finished completing the form, use the Submit Health History button to send your information to the clinic.