An accurate Health History Form is vital to ensure that it is safe for you to receive Massage Therapy. Please keep this form up to date with any changes in your health. All information gathered for this treatment is confidential, except as required or allowed by law. You will be asked to provide written authorization for release of any information. When filling out this form please take your time and print clearly. If there is not sufficient room, please use the back of this page.
Client Name ____________________________________________…
Street Address ________________________________________
City ____________________ Postal Code ___________________
Contact # _________________ E-Mail _______________________
DOB ____________________ Age _________ Height _________
Occupation ______________________________________________
Recreation Activity _______________________________________
Emergency Contact name & # ____________________________
Family Physician & # _____________________________________
Primary complaint? ______________________________________
Do you know what has caused this?
__________________________________________________________
What have you tried for relief? ____________________________
Please list all medications _______________________________
Please list ALL past surgeries & resulting complications
__________________________________________________________
Please list prior car accidents & / or significant injuries. Including physical limitations resulting from these injuries:
_________________________________________________________,,
Have you previously seen an RMT? □ Yes □ No
Are you seeing other Health Care Professionals? □ Yes □ No
If yes, please explain _____________________________________
Please check all that apply
□ Head Trauma / Concussion □ Headaches □ Whiplash □ Vision Problems □ Ear Problems □ Ringing in the Ears □ Recent Dental work □ TMJ dysfunction or Grinding □ Neck Pain □ Shoukder Pain □ Elbow Pain □ Wrist / Hand Pain □ Low Back Pain □ Hip Pain □ Knee Pain □ Feet trouble □ Plantar Fasciitis □ Stiff / Swollen Joints □ Osteoporosis □ Arthritis □ Degenerative Disk Disease □ Scoliosis □ Bursitis □ Fractures / Dislocations □ Poor Posture □ Fibromyalgin Presence of: □ Internal Pins / Wires □ Artificial Joints □ Pacemaker □ Special Equipment CARDIOVASCULAR □ High Blood Pressure □ Low Blood Pressure □ Heart Condition / Disease □ Diabetes □ Varicose Veins □ Stroke / CVA □ Chest pain / Angina □ Cold hands and / or feet □ Poor healing / Bruise easily □ Myocardial infarction □ Fatigue □ Hyperglycaemia NERVOUS SYSTEM □ Epilepsy □ Loss of Sensation □ Sciatica □ Psychosis □ Multiple Sclerosis □ Cerebral palsy □ Insomnia IMMUNE SYSTEM □ Cancer □ Allergies / Sinusitis □ Anaphylactic Reaction to anything □ AIDS / HIV □ Hepatitis A, B or C DIGESTIVE □ Constipation □ Diarrhea □ Liver / Gallbladder □ Kidney / Bladde □ Diverticulitis □ Ulcerr □ Irritable Bowel Syndrome □ Crohn’s Disease RESPIRATORY □ Chronic Cough □ Shortness of Breath □ Bronchitis □ Asthma □ Emphysema SKIN □ Sensitive skin □ Rashes / Ruptures Contagious Conditions □ Cold Sores □ Shingles OTHER □ Pregnant (Due _________) □ Menopause □ Fibromyalgin
Good Sleeping Habits □ Yes □ No
Regular Eating Habits □ Yes □ No
Regular Exercise □ Yes □ No
High Work / Family Stress □ Yes □ No
I have answered the above and to the best of my knowledge all information is correct and accurate.
Date ______________ Signature ____________________________
Bryson Ingram R.M.T. 