Massage Therapy Health History Form

Massage Therapy Health History Form
Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4 W: www.greenbasehealth.com E: [email protected] T: 519-574-5151
The information requested below will assist in treating you safely and effectively. Feel free to ask questions of the information being requested and note
that all information will be kept confidential unless you grant us written permission to share it if needed.
Name: ____________________________________________
Date of Birth: __________________________
Address: __________________________________________________________________________________
Primary Phone #: __________________________________ Email: _________________________________________________________
Would you prefer to be contacted by Phone ⃝
or Email ⃝
Primary Care Physician Name and Address: ____________________________________________________________________________
Emergency Contact: _____________________________________________ Phone: __________________________________________
What is your Occupation? __________________________________________________________________________________________
How did you hear about us? ________________________________________________________________________________________
Check if you would like to receive our online Newsletter ⃝
Please indicate below conditions your are experiencing or have experienced:
Cadiovascular
⃝ High Blood Pressure
⃝ Low Blood Pressure
⃝ Chest Pain/ Angina
⃝ Chronic Congestive Heart Failure
⃝ Heart Attack
⃝ Phlebitis/ Varicose Veins
⃝ Stroke/CVA
⃝ Pacemaker or similar device
⃝ Heart Disease
Is there a family history of
the above? ______
Head and Neck
⃝ Headaches
Frequency ___________
⃝ Migraines
Frequency ___________
⃝ Dizziness
⃝ Brain Injury
⃝ Vision Problems
⃝ Vision Loss
⃝ Ear Problems
⃝ Hearing Loss
⃝ Sinus Pain
Respiratory
⃝ Chronic Cough
⃝ Asthma
⃝ Shortness of Breath
⃝ Bronchitis
⃝ Emphysema
Is there a family history of
the above? ______
Other Conditions
⃝ Numbness/ Loss of Sensation
⃝ Bruise Easily
⃝ Light Headed
⃝ Fatigue
⃝ Fibromyalgia
⃝ Edema
⃝ Osteoarthritis
⃝ Rheumatoid Arthritis
⃝ Osteoporosis
⃝ Digestive Problems
⃝ IBS/Crohns/Colitis
⃝ Nausea
⃝ Ulcer
⃝ Diabetes
⃝ Epilepsy
⃝ Cancer: _____________
⃝ Mental Illness:_______________
Infections
⃝ Hepatitis
⃝ Skin Conditions
⃝ Rash
⃝ TB
⃝ HIV
⃝ Herpes
⃝ Warts
Other: ______________
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Allergies: ________________________________
Pins, wires, plates or artificial joints?
Please Specify:____________________________
________________________________________
Do you Smoke?: YES ⃝ NO ⃝
Do you exercise?: YES ⃝ NO ⃝
Other Conditions: _________________________
________________________________________
Overall, how is your general Health?
________________________________________
Women Only
Are you Pregnant? YES ⃝ NO ⃝
Due Date: ________________________________
Menstrual Problems or Conditions?
_________________________________________
_________________________________________
Date of Initial Health History:
Update 1: _______________
Update 2: _______________
OFFICE USE
Update 3: _______________
ONLY
Update 4: _______________
Have you had massage therapy in the past? Yes ⃝ No ⃝ When was your last treatment? ___________________________________
What’s your reason for having a massage today?________________________________________________________________________
How did this condition star? ________________________________________________________________________________________
Do you have a goal or outcome you want to see with your massage therapy treatment? ________________________________________
On the diagram below, please indicate areas of concern (pain, tension, inflammation, reduced range of motion, etc)
Have you experienced any injuries, surgeries or accidents? Please list them along with the approximate time they occurred and any treatment you received: __________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Have you ever been hospitalized? If so, please indicate when and why: ________________________________________________________
__________________________________________________________________________________________________________________
If you are currently on any supplements or medication please indicate what they are and the reason you take them: ___________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
I, __________________________________ ,declare that the above information is correct and if, in the future, my health information should
change, I acknowledge that it is my responsibility to inform Robyn Ellis RMT either before or at my next scheduled appointment. I
understand that all the information I have given on this form is confidential and I have to right to ask
questions regarding my massage treatment and that I have the right to stop or modify my treatment at
any time. I also understand that a minimum of 24 hours notice is required to avoid missed/cancelled
appointment fees ($30) if I need to cancel or reschedule my appointment.
Signature: ______________________________________Date:________________________
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Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4
W: www.greenbasehealth.com E: [email protected] T: 519-574-5151