Health Form



Health Forms

Name: ______________________________________ DOB: ____________
Address: ________________________________________State: _______ Zip: ___________
Phone: (Home) ___________________ (Work) _________________ (Cell) _______________
Emergency Contact: ____________________________ Phone: ________________________
How did you hear about this place: _______________ E-mail address: __________________

*If you have a specific medial condition or symptom, receiving or performing massage may be contraindicated or require modification. A referral from your primary care provider may be requested prior to receiving &/or performing massage.
DISCLAIMER: This place of business will not be held liable for any injury or condition that arises from application of massage despite completion of this form. The form is intended as an assessment tool that is routinely used in the massage profession and serves as a guide for application of massage. Your e-mail address will not be sold or given to anyone else.

*Have you received a professional massage before? _____________________________
*Are you on any medications (List them)? ____________________________________

*Are there any areas of your body that you ‘DO NOT’ want massaged:
(Face) (Scalp) (Neck) (Upper Chest) (Shoulders) (Stomach) (Upper back) (Mid back) (Lower back) (Arms) (Hands) (Side of glutes) (Legs) (Feet)

*Please circle the condition/s that you have now or had experienced in the past & add
comments to clarify.

Integumentary System (Skin)
•        Boils
•        Fungal infections
•        Herpes Simplex
•        Warts/moles
•        Eczema
•        Psoriasis
•        Skin Cancer
•        Skin allergies
•        Rashes
•        Burns including Sunburn
•        Scars
•        Cosmetic surgery
•        Bruise easily
•        Other: _____________________________________
•        Comments: _________________________________

Circulatory/Lymph/Endocrine System
•        Anemia
•        Phlebitis
•        Heart disease/condition
•        High Blood Pressure
•        Low Blood Pressure
•        Varicose Veins
•        Diabetes
•        Clotting disorders
•        Edema
•        Hodgkin’s disease
•        AIDS, HIV
•        Chronic Fatigue Syndrome
•        Lupus
•        Cold/flu/fever (Currently)
•        Hypo/Hyperthyroidism
•        Leukemia/lymphoma
•        Other: _____________________________________
•        Comments__________________________________

Respiratory System (Breathing)
•        Sinus problems
•        Tuberculosis
•        Asthma/Emphysema
•        Other: _____________________________________
•        Comments: _________________________________

Musculo-skeletal System (Muscle)
•        Fibromyalgia
•        Rheumatoid Arthritis
•        Osteoarthritis
•        TMJ dysfunction
•        Strains, sprains, tendonitis
•        Bursitis
•        Carpal tunnel syndrome
•        Thoracic outlet syndrome
•        Cramping, spasms, soreness
•        Broken or fractured bones
•        Persistent pain
•        Loss of motion or mobility
•        Difficulty with prolonged stance
•        Unable to comfortably lie on both sides
•        Other: _____________________________________
•        Comments: _________________________________

Digestive/Urinary System
•        Cirrhosis
•        Ulcer
•        Gallstones
•        Hepatitis
•        Irritable Bowel Syndrome
•        Kidney stones
•        Reflux esophagitis
•        Bladder infection
•        Eating disorder
•        Other: _____________________________________
•        Comments: _________________________________

Nervous System
•        Multiple Sclerosis
•        Spinal cord injury
•        Brain injury
•        Numbness/tingling
•        Headaches
•        Stroke
•        Seizure disorder
•        Reduced sensation
•        Other:______________________________________
•        Comments: _________________________________

Reproductive System
•        Breast Cancer
•        Ovarian cysts
•        Painful Menstruation
•        Pregnant
•        Prostate Cancer
•        Pelvic Inflammatory Disease
•        Other: _____________________________________
•        Comments: _________________________________

Other
•        Hearing impaired
•        Visually impaired
•        Insomnia
•        Cancer (Other than specified above)
•        Alcoholism/substance abuse
•        Heavy caffeine or nicotine user
•        Physical abuse
•        Psychological condition
•        Taking prescribed medication
•        Using over the counter medication
•        Accidents: _______________________________________________________________
•        Surgery other than specified above:____________________________________________
•        Other conditions: __________________________________________________________
•        Comments: ______________________________________________________________

I have stated all conditions that I am aware of and that this information is true and accurate to the best of my knowledge. I agree to inform my massage therapist immediately of any change in conditions as stated above. I acknowledge that this information is confidential and intended for review by fellow massage therapists; that a medical referral may be requested of me; and that ‘’This place of business’ is not held liable for the management or arising of conditions.

Signature: ___________________________________________ Date: __________________