Health History Form
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2Ken Shim, RMT – Health History Form
An accurate health history is important to ensure that it is safe for you to receive a massage treatment. If your health status changes in the future,
please inform your therapist. All information gathered for this treatment is confidential except as required or allowed by law or except to
facilitate diagnosis (assessment) or treatment. You will be asked to provide written authorization for release of any information.
PERSONAL INFORMATION
Name:_______________________________________________
Today’s Date ___________________________________________________
Phone (Home) ____________________(cell)________________
Date of Birth ___________________________________________________
(Work) ________________________________________
Primary Complaint _______________________________________________
Address _____________________________________________
Occupation _____________________________________________________
City ________________________ Postal Code______________
Physician & Address _____________________________________________
Email _______________________________________________
Who referred you? ______________________________________________
HEALTH HISTORY
Please indicate all current and past conditions you have experienced.
Head/Neck
Current
Past
Respiratory/Lungs
Current
Past
Digestive
Current Past
Whiplash
Asthma
Constipation
Headache
Bronchitis
Diarrhea
Migraine
Emphysema
Crohn's Disease
Irritable Bowel Syndrome
Concussion
Shortness of breath
Ringing in the ears
Chronic cough
Ulcers
Hearing loss
Other:
Diverticulitis
Vision problems
Is there a family history of any of the above?
Nausea
Brain injury
TMJ (Jaw Pain)
Other:
Other:
Cardiovascular
Current
Past
Nervous System
Current Past
Infections
Current
Past
High blood pressure ____/____
Spinal cord injury
Hepatitis
Low blood pressure ____/____
Seizures/Epilepsy
Type:
Heart attack
Numbness/Tingling
Infectious skin
Chronic congestive heart failure
Where?
conditions
Stroke/CVA
Type?
Pacemaker or similar device
Other:
TB
Phlebitis/Varicose veins
HIV
Heart Disease
Herpes
Other:
Other:
Is there a family history of
Artificial Joints, plates, pins
any of the above?
Disease/condition
Current
Past
WomenOnlv
Current Past
Bone/Joint
Current
Past
Cancer _______________________
Pregnancy
Dislocation/Fracture
Diabetes _______________________
Vaginal Birth/abortion
Osteoarthritis
Treatment:
Due Date:
Rheumatoid Arthritis
Fibromyalgia
Degenerative disc disease
Chronic Fatigue Syndrome
Current gynaecological conditions:
Herniated disc
Allergies ______________________
Other:
Other
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