Massage Therapy Intake Form - Full Circle Health Care printable pdf download

Health History Form

(PLEASE PRINT)

Name:__________________________________________ Telephone: (Home)______________________

(Cell)______________________

Street:__________________________________________ City:________________ Postal Code:________

Date of Birth:_______/_______/________ Age:_______________

YYYY

E-Mail: _________________________________________________

Doctor:___________________

Occupation:_____________________________________________

Address:__________________

First time for massage therapy? ○Yes ○No

__________________________

Who can we thank for referring you?________________________

Phone:____________________

Goals for Massage Therapy today?

○Relaxation

○Pain relief

○Maintenance

○Other_______________________________

What area(s) of the body would you like to focus treatment on?

__________________________________________________________________________________________

Are there areas that you prefer not to have treated? _____________________________________________

Are you presently taking any medication? ○Yes ○No

Condition Treating: ________________________________________________________________________

Are you currently receiving treatment from another health care professional? ○Yes ○No

If yes, please explain: _______________________________________________________________________

__________________________________________________________________________________________

Date and nature of injury____________________________________________________________________

__________________________________________________________________________________________

How often do you experience your symptoms?

○Constantly (76-100%) ○Frequently (50-75%) ○Occasionally (26-50%) ○Intermittently (0-25%)

How would you describe the type of pain?

○Sharp ○Numb ○Dull ○Tingly ○Diffuse ○Achy ○Burning ○Shooting ○Other____________________

Have you had surgery? Date: _________________ Nature: ________________________________________

Note: An accurate health history is important to ensure that massage therapy is safe for you to receive.

Massage Therapy Intake Form - Full Circle Health Care