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
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.
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
Reason
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
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.
