Health History Intake 2024
Required Field
Personal Info
First Name
Last Name
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
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Day
1
2
3
4
5
6
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10
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13
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17
18
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20
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31
Year
2026
2025
2024
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1980
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1955
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1953
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1912
1911
1910
1909
1908
1907
Gender
Male
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Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
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Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
General Health
General Health
General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Current Medications: Please List
Injuries
Surgeries
Additional Info
Massage Preferences
Table Temperature
Low/Off
Warm
Very Warm
Positional Considerations:
Supine Only: I can only lie face up
Prone Only: I can only lie face down
Sidelying: I can only lie on my side
Require Additional Support/ Bolstering
Supine: Require elevated head and neck.
Supine: Require Additional bolstering behind knees
Prone: Require face down back support (belly pillow)
Health History Details
Current Complaint
Current Complaint: Reason for seeking Massage Therapy
Pain Severity: 1-10
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Date of Injury?
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Other therapies
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Conditions
Asthma
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Concussion
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Depression
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Epilepsy
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Hearing Impairment
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Heart Defect
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Heart Attack
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Heart Surgery
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Other Heart Condition
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Meniere Disease
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Mood Disorder
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Pacemaker
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PTSD
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Schizophrenia
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Stroke
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Vertigo
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Long Covid
With continued medical intervention
Without medical intervention
TMJ (Jaw)
Ear Pressure/Ringing
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Clenching/Grinding
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Clicking
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Jaw Pain
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Difficulty Chewing
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Locking
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Difficulty Opening Jaw
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Difficulty Swallowing
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Well Being
Smoking
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Sports
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Drinking
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Caffeine
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Exercise
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Flexibility
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Mobility/Walking Aids
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Range of Motion
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Infectious: History of Chronic Infections
Strep
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Epstein Barr
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Lyme Disease
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Pneumonia
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Emotion / Memory
Alzheimer Disease
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Schizophrenia
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Substance Use Disorder
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Genetics
Mitochondrial Disease
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Down Syndrome
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Ehlers-Danlos Syndromes
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Loeys-Dietz Syndrome
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Marfan Syndrome
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Other
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Migraines
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Rebound
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Sinus
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Tension
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Chronic Daily Headache
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Cluster
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Other Headaches
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Reproductive
Premenstrual Syndrome
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Endometriosis
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Prostatitis
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Enlarged Prostate
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Uterine Disorder
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Gynaecological Conditions
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Menopause
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Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Breast Disorder
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Pregnancy
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Ectopic Pregnancy
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Other Reproductive
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Musculoskeletal
Myasthenia Gravis
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Amyotrophic Lateral Sclerosis (ALS)
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Recti Diastasis
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Fibromyalgia
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Osgood-Schlatter Disease
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Ankylosing Spondylitis
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Scleroderma
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Chronic Fatigue Syndrome
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Torticollis
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Fracture
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Osteoarthritis
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Arthritis
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Scoliosis
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Chronic Myofascial Pain Syndrome
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Whiplash
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Gout
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Osteomalacia
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Artificial Joints / Special Equipment
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Compartment Syndrome
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Hereditary/Congenital Deformity
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Osteoporosis
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Baker's Cyst
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Spasms / Cramps
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Degenerative Disk Disease
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Jaw Pain (TMJD)
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Paget Disease
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Bone Disease
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Spondylolisthesis
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Dislocation
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Joint Injury
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Joint Stiffness / Swelling
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Plantar Fasciitis
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Bone or Joint Disease
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Strain/Sprain
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Dupuytren's Contracture
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Muscular Dystrophy
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Adhesive Capsulitis
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Psoriatic Arthritis
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Broken Bone / Fracture
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Temporomandibular Joint Dysfunction
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Ehlers-Danlos Syndrome
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Other Musculoskeletal
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Blood
Fainting Spells
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Stroke
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Haemophilia
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Thrombosis/Embolism
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Hepatitis
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High Cholesterol
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HIV
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Anemia
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HIV/AIDS
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Bleeding Disorder
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Hypercoagulability
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Blood Thinner Medication
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Polycythemia
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Other Blood
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Cardiovascular
Cold Hands
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High Blood Pressure
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Phlebitis
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Blood Pressure
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Congenital Heart Defect
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Hyperlipidemia
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Postural Orthostatic Tachycardia Syndrome
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Cardiac Arrhythmia
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Congestive Heart Failure
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Low Blood Pressure
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Raynaud Disease
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Cardiovascular Accident
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Coronary Artery Disease
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Lymphedema
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Acute Coronary Syndrome
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Rheumatic Heart Disease
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Cardiovascular Conditions
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Fainting Spells
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Myocardial infarction
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Aneurysm
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Stroke
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Chest Pain
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Heart Attack
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Pacemaker
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Angina
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Swelling
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Chronic Ischemic Heart Disease
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Heart Condition
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Pericarditis
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Atherosclerosis
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Valve Disorders
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Chronic Venous Insufficiency
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Heart Disease
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Peripheral Vascular Disease
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Blood Clots
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Varicose Veins
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Cold Feet
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Other Cardiovascular
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Neurological
Multiple Sclerosis
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Stabbing Pain
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Chronic Pain Disorder
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Numbness
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Stroke
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Dizziness
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Epilepsy
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Parkinsons
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Tingling
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Fatigue
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Peripheral Neuropathy
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Transient Ischemic Attacks (TIA)
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Fibromyalgia
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Sciatic Pain
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Vertebral and Spinal Cord Injury
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Brain Injury
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Herniated Disc
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Seizure Disorder
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Burning
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Huntington Disease
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Shingles
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Carpal Tunnel
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Loss of Sensation
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Sleeping Disorders
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Cerebral Palsy
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Other Neurological
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Skin
Rosacea
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Hypersensitive Reactions
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Skin Conditions
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Allergic Dermatosis
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Infectious Skin Conditions
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Melanoma/Carcinoma
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Skin Irritations
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Athlete's Foot
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Moles
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Surgical Scars
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Bruise Easily
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Non-Surgical Scars
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Urticaria
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Dermatographia
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Plantar's Wart
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UV Burn
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Eczema
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Psoriasis
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Herpes
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Rash
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Other Skin
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Immune
Cancer
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Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Sjogren's Syndrome
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HIV/Aids
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Hodgkin Lymphoma
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Infectious Mononucleosis
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Leukemia
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Allergies
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Lupus
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Anaphylaxis
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Other Immune
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Respiratory
Asthma
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Bronchitis
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Chronic Cough
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COPD
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Cystic Fibrosis
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Emphysema
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Respiratory Tract Infection
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Shortness of Breath
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Sinus Problem
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Tuberculosis
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Other Respiratory
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Gastrointestinal
Diarrhea
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Digestive Conditions
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Eating Disorder
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Esophageal Disorder
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Hiatal Hernia
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Irritable Bowel Syndrome
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Abdominal Hernia
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Stomach Disorders
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Acid Reflux
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Other Gastrointestinal
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Hearing
Ear Problems
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Hearing Loss
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Tinnitus
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Vertigo
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Other Hearing
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Family History
Arthritis
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Cancer
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Cardiovascular
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Diabetes
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Respiratory
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Endocrine
Adrenal Fatigue
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Blood Sugar Managed?
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Diabetes
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Hyperthyroidism
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Hypothyroidism
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Pituitary and Growth Disorder
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Other Endocrine
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Kidney
Kidney Stones
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Urinary Incontinence
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Urinary Tract Infection Frequent/ Currently
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Other Kidney
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General Injury Related Questions
What is the next competition/challenge?
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Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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Pain medications or steroids
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Surgery (type/year)
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Complications?
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Miscellaneous
Weakened Immune Function
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Liver Disease
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Surgical Pins or Wire
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Loss of Balance
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Insomnia
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Mental Health Issues
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Autism
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ADHD
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Dental: Bridge, Dentures or Implants
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Contact Lens
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Visually Impaired/Vision Loss
Characters:
0
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Other Medical Conditions
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0
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Other Diagnosed Diseases
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0
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Which best describes what you are experiencing
Pain
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0
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Mild
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0
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Getting Worse
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0
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Ache
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0
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Moderate
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0
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Staying the Same
Characters:
0
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Tension
Characters:
0
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Disabling
Characters:
0
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Getting Better
Characters:
0
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Discomfort
Characters:
0
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Constant
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0
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Imbalance
Characters:
0
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Intermittent
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0
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Increases with Activity
Characters:
0
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Decreases with Activity
Characters:
0
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No Change
Characters:
0
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Other
Characters:
0
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Allergy
Environmental
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0
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Food
Characters:
0
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Latex
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0
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Medical
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0
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Miscellaneous
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0
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Emotion / Mood
Physical Abuse History
Characters:
0
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Rate the stress in your life (1-10)
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0
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Anxiety
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0
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Mental Abuse History
Characters:
0
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Other Emotions
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Massage Goals and Preferences
Reduce Pain
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Improve Symptoms
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0
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Rehabilitation: Injury/Surgery
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0
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Stress Relief/Anxiety
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Trauma Recovery
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Preferred Pressure
Light
Medium
Firm
Require positional accommodations
Must be Supine/Face Up
Must be Prone/ Face Down
Require Side Lying
Joint Replacement(s)
Date of last Massage
Massage Frequency
Characters:
0
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Other
Characters:
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