Health History Form

Is this your first massage?

Did a health care provider refer you for massage therapy

Are you experiencing any of the following symptoms: chronic pain, fatigue, tension, swelling, numbness, or inflammation?

Please list any recent/current injuries, and dates of occurance

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Were these injuries sustained as a result of a motor vehicle accident?

Were these injuries sustained at work?

Have you received treatment from another health care professional in the past year?

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Allergies? If yes, list your allergies, and indicate whether they require an epi-pen

Are you taking any medications or substance that may affect your sensitivity, healing, or ability to receieve massage (e.g. blood thinners, corticosteroids, pain medications, recreational drugs)?

List any health issues you have related to the following categories that may impact your massage therapy care

Muscle, joint or bone issues (e.g. arthritis, muscle strain)

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Heart or circulation concerns (e.g. high blood pressure)

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Nearological symptoms or conditions (e.g. dizziness, numbness, epilepsy/seizures, stroke, multiple sclerosis)

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Skin conditions that may impact your reaction to treatment (e.g. bruise easily, eczema, rashes)

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Gynecological concerns (e.g. pregnancy, menstral concerns, menopause)

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Other conditions that may impact your massage therapy care

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Physical Symptoms Related to Mental Health (e.g. stress, anxiety, depression)

Mental health concerns can contribute to physical symptoms such as musculoskeletal pain, and many of these physical symptoms can be addressed by massage therapy. Are you experiencing physical symptoms such as fatigue, tension, or sleep disturbances that may relate to mental health?

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