Massage Health History
Required Field
Personal Info
First Name
Last Name
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
Gender
Male
Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work 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
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
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
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
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
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
Other
Medical Info
Primary Complaint
Characters:
0
/255
General Health
Characters:
0
/255
Current Treatment
Characters:
0
/255
Past Treatment (from other practitioners)
Characters:
0
/255
Medications
Injuries
Surgeries
Additional Info
Conditions
Health Questions
Vertigo
Characters:
0
/255
Asthma
Characters:
0
/255
Epilepsy
Characters:
0
/255
Meniere Disease
Characters:
0
/255
Warts
Characters:
0
/255
Blood thinner medication
Characters:
0
/255
Gastrointestinal
Characters:
0
/255
Migraines/Headaches
Characters:
0
/255
Cancer
Characters:
0
/255
Hearing Impairment
Characters:
0
/255
Mood Disorder
Characters:
0
/255
Cardiovascular
Characters:
0
/255
Heart Attack
Characters:
0
/255
Pacemaker
Characters:
0
/255
Concussion
Characters:
0
/255
Heart Condition
Characters:
0
/255
Past Heart Surgery
Characters:
0
/255
Congenital Heart Defect
Characters:
0
/255
High blood pressure
Characters:
0
/255
Schizophrenia
Characters:
0
/255
Stroke
Characters:
0
/255
Depression
Characters:
0
/255
HIV/Aids
Characters:
0
/255
Varicose veins
Characters:
0
/255
Diabetes
Characters:
0
/255
Low blood pressure
Characters:
0
/255
Treatment Goals
Improve Symptoms
Characters:
0
/255
Improve Well Being
Characters:
0
/255
Pain Relief
Characters:
0
/255
Rehabilitation
Characters:
0
/255
Stress Relief
Characters:
0
/255
Support in Healing/Recovery
Characters:
0
/255
Health Advice for Healing
Characters:
0
/255
Improve Lifestyle
Characters:
0
/255
Other
Characters:
0
/255
Well Being
Drinking
Characters:
0
/255
Smoking
Characters:
0
/255
Exercise
Characters:
0
/255
Sports
Characters:
0
/255
Sugar Intake
Characters:
0
/255
Flexibility
Characters:
0
/255
Supplements
Characters:
0
/255
Hobbies
Characters:
0
/255
Water Intake
Characters:
0
/255
Interests
Characters:
0
/255
Mobility/Walking Aids
Characters:
0
/255
Range of Motion
Characters:
0
/255
Caffeine
Characters:
0
/255
Salt Intake
Characters:
0
/255
Infectious
Epstein Barr
Characters:
0
/255
Lyme Disease
Characters:
0
/255
Pneumonia
Characters:
0
/255
Strep
Characters:
0
/255
Area of Complaint
Neck
Characters:
0
/255
Left Side of Neck
Characters:
0
/255
Right Side of Neck
Characters:
0
/255
Upper Back
Characters:
0
/255
Left Side of Upper Back
Characters:
0
/255
Right Side of Upper Back
Characters:
0
/255
Mid Back
Characters:
0
/255
Left Side of Mid Back
Characters:
0
/255
Right Side of Mid Back
Characters:
0
/255
Low Back
Characters:
0
/255
Left Side of Low Back
Characters:
0
/255
Right Side of Low Back
Characters:
0
/255
Chest
Characters:
0
/255
Abdomen
Characters:
0
/255
Left Arm
Characters:
0
/255
Right Arm
Characters:
0
/255
Left Shoulder
Characters:
0
/255
Right Shoulder
Characters:
0
/255
Left Elbow
Characters:
0
/255
Right Elbow
Characters:
0
/255
Left Wrist
Characters:
0
/255
Right Wrist
Characters:
0
/255
Left Hand
Characters:
0
/255
Right Hand
Characters:
0
/255
Left Leg
Characters:
0
/255
Left Thigh
Characters:
0
/255
Left Calf
Characters:
0
/255
Right Leg
Characters:
0
/255
Right Thigh
Characters:
0
/255
Right Calf
Characters:
0
/255
Left Gluteal
Characters:
0
/255
Right Gluteal
Characters:
0
/255
Left Hip
Characters:
0
/255
Right Hip
Characters:
0
/255
Left Knee
Characters:
0
/255
Right Knee
Characters:
0
/255
Left Ankle
Characters:
0
/255
Right Ankle
Characters:
0
/255
Left Foot
Characters:
0
/255
Right Foot
Characters:
0
/255
Sacrum
Characters:
0
/255
Tailbone (coccyx)
Characters:
0
/255
Headaches
Cluster
Characters:
0
/255
Headaches
Characters:
0
/255
Migraines
Characters:
0
/255
Rebound
Characters:
0
/255
Sinus
Characters:
0
/255
Tension
Characters:
0
/255
Chronic Daily Headache
Characters:
0
/255
Other Headaches
Characters:
0
/255
Neurological
Seizure Disorder
Characters:
0
/255
Burning
Characters:
0
/255
Tingling
Characters:
0
/255
Dizziness
Characters:
0
/255
Vertebral and Spinal Cord Injury
Characters:
0
/255
Herniated Disc
Characters:
0
/255
Multiple Sclerosis
Characters:
0
/255
Numbness
Characters:
0
/255
Peripheral Neuropathy
Characters:
0
/255
Sciatic Pain
Characters:
0
/255
Other Neurological
Characters:
0
/255
Immune
Lupus
Characters:
0
/255
Rheumatoid Arthritis
Characters:
0
/255
Other Immune
Characters:
0
/255
Skin
Psoriasis
Characters:
0
/255
Rash
Characters:
0
/255
Severe Irritability
Characters:
0
/255
Skin Conditions
Characters:
0
/255
Athlete's Foot
Characters:
0
/255
Skin Irritations
Characters:
0
/255
Bruise Easily
Characters:
0
/255
UV Burn
Characters:
0
/255
Eczema
Characters:
0
/255
Plantar's Wart
Characters:
0
/255
Musculoskeletal
Joint Stiffness / Swelling
Characters:
0
/255
Osteoarthritis
Characters:
0
/255
Plantar Fasciitis
Characters:
0
/255
Arthritis
Characters:
0
/255
Scoliosis
Characters:
0
/255
Carpal Tunnel Syndrome
Characters:
0
/255
Spasms / Cramps
Characters:
0
/255
Chronic Fatigue Syndrome
Characters:
0
/255
Tendonitis/Bursitis
Characters:
0
/255
Torticollis
Characters:
0
/255
Fibromyalgia
Characters:
0
/255
Whiplash
Characters:
0
/255
Jaw Pain (TMJD)
Characters:
0
/255
Other Musculoskeletal
Characters:
0
/255
General Injury Related Questions
Previous sports-related injuries?
Characters:
0
/255
Treatment of previous injury?
Characters:
0
/255
Physical Therapy
Characters:
0
/255
Chiropractic
Characters:
0
/255
OTC medications
Characters:
0
/255
Pain medications or steroids
Characters:
0
/255
Surgery (type/year)
Characters:
0
/255
Complications from that injury?
Characters:
0
/255
Miscellaneous
Surgical Pins or Wire
Characters:
0
/255
Prenatal (check boxes to enter details below)
Any pregnancy complications or health issues?
Characters:
0
/255
Weeks Pregnant
Characters:
0
/255
Blood Clot (Phlebitis)
Characters:
0
/255
Diabetes
Characters:
0
/255
Edema/Swelling
Characters:
0
/255
Nausea
Characters:
0
/255
Pre-eclampsia (toxemia)
Characters:
0
/255
Sciatica
Characters:
0
/255
Previous C-Section
Characters:
0
/255
High Risk Pregnancy
Characters:
0
/255
Postpartum (check boxes to enter details below)
Any birth/postpartum complications or health issues?
Characters:
0
/255
Currently lactating or nursing?
Characters:
0
/255
Have you seen your midwife/OBGYN since giving birth?
Characters:
0
/255
Number of weeks postpartum
Characters:
0
/255
Allergy
Latex
Characters:
0
/255
Mastocytosis
Characters:
0
/255
MCAD
Characters:
0
/255
Medical
Characters:
0
/255
Miscellaneous
Characters:
0
/255
Coconut Oil
Characters:
0
/255
Sensitive to scents/essential oils
Characters:
0
/255
Environmental
Characters:
0
/255
Food
Characters:
0
/255
Other Allergies
Characters:
0
/255
Submit Form
×