Massage Therapy Health History, Consent Form
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2Massage Therapy Health History Form
Leslie Brown RMT, Harold Duggan M.A. RMT, Sylvia Bragg-Smith RMT
Daniella Mihajlovic RMT, Andrea Ruiter RMT, Brook Bennie RMT,
Leah Styles RMT
The information requested below will assist us in treating you safely and effectively. Please note that all information provided below will be
kept confidentially unless allowed or requested by law (your written permission will be required). If at any time you have any questions
regarding your visit, please feel free to ask!
Name:________________________________ Phone: (H) _________________ (W) _______________
E-mail: _______________________________ Cell phone: _________________ Today’s Date: _______
Address: ______________________________ City: _____________________ P.C. ________________
Occupation: ___________________________ Date of Birth: __________________________________
Your Primary Care Physician - Name & address: _____________________________________________
Where did you hear about our clinic?_____________________ Have you had a massage before?
_ YES
_ NO
What brings you in for a massage? _______________________________________________________________
Overall, how is your general health? ______________________________________________________________
Please indicate conditions you are experiencing or have experienced:
CARDIOVASCULAR
WOMEN
OTHER CONDITIONS
Current/Previous
Current/Previous
Current/Previous
_
_
_ High Blood Pressure
_ Menstrual Problems
_
_ Liver
_
_ Low blood Pressure
_
_ Gynecological
_
_ Gall Bladder
_
_ Chronic Congestive
Conditions:
_
_ Kidney/Bladder
Heart Failure
What? ______________
_
_ Diabetes -
_
_ Heart Attack
Pregnant? _ YES _ NO
Onset ______________
_
_ Phlebitis/Varicose Veins
Due Date: ____________________
_
_ Insomnia
_
_ Stroke/CVA
Number of Children: ____________
_
_ Cancer -
_
_ Pacemaker or
Where? ____________
similar device
_
_ Epilepsy
_
_ Poor Circulation
INFECTIONS
_
_ Constipation
_
_ Heart disease
_
_ Digestive Difficulties
Current/Previous
_
_ Hepatitis
_
_ Allergies/hypersensitivity
_
_ Herpes
What? _____________
_
_ Skin Conditions
_
_ Loss of Sensation
RESPIRATORY
_
_ TB
Where? ____________
Current/Previous
_
_ HIV/AIDS
_
_ Arthritis, or family history
_
_ Chronic Cough
of? 1 YES 1 NO
_
_ Shortness of Breath
Affected Areas:_______
_
_ Bronchitis
OTHER HEALTH CARE
_
_ Any internal wires, pins,
_
_ Asthma
artificial joints?
_
_ Emphysema
Current/Previous
_
_ Massage Therapy
Where? ____________
_
_ Breathing Problems
_
_ Chiropractic
_
_ Physiotherapy
_
_ Psychotherapy
PREVIOUS
HEAD/NECK
_
_ Regular Exercise
INJURIES/SURGERIES
Current/Previous
_
_ Headaches:
Type: ______________
Nature:_______________________
CURRENT MEDICATIONS
_
_ Vision Problems/Loss
Date: ________________________
Medication: ___________________
_
_ Earaches
Condition:_____________________
_
_ Vertigo/Dizzyness
Nature:_______________________
_
_ TMJ Dysfunction
Date: ________________________
Medication: ___________________
Condition:_____________________
Nature:_______________________
Date: ________________________
Medication: ___________________
Condition:_____________________
Please turn over and fill out back of form ....
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