Health History Form Page 2
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1
2Year
Accidents/Injuries/Operations
Year
Accidents/Injuries/Operations
Current medications and the conditions they treat: __________________________________________________________________________
For your current condition, have you tried any of the following (Use an ‘X’ if it was unsuccessful or a ‘√’ if it was successful):
Massage
Chiropractic
Physiotherapy
Acupuncture
Osteopath
Yoga
Pilates
Stretching & Exercise
Are you physically active?
Yes
No
Previous massage experience:
Yes
No
How often? ____________________________
Good sleeping habits:
Yes
No
Type of exercise: ________________________
Regular eating habits:
Yes
No
Current Symptoms:
1. On the diagram, use the following letters to indicate the
locations of your pain:
A - Ache/Dull pain
P - Pins & Needles/Tingling
B – Burning
N - Numbness
2. Beside each letter, mark the intensity of pain with a
number from 1 to 10 (i.e. 0 - no pain, 10 - child birth)
What is your general level of pain now (0 – 10)? ________
What is the level of your pain at its worst (0-10)? _______
How often do you feel the pain? ____________________
When did the pain start? __________________________
What caused it?
What movements or activities make the pain worse?
What relieves the pain? __________________________
_______________________________________________
What has the pain stopped you from doing? _________________________________________________________________________
_____________________________________________________________________________________________________________
What goals do you want massage therapy to accomplish for you? _______________________________________________________
_____________________________________________________________________________________________________________
List any areas that you do not want treated: _________________________________________________________________________
Date
______________________________
Date
_____________________________
Client’s Signature
______________________________
Therapist’s Signature
_____________________________
Update 1 _______________________
Update 2 _______________________
Update 3 _______________________
Update 4 _______________________
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Parent category: Medical