Massage Experts Bedford | Health History Form
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Medical Info
Primary Complaint
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General Health
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Past Heart Surgery
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Diabetes
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Varicose veins
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Vertigo
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Epilepsy
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Hearing Impairment
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Heart Condition
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Treatment Goals
Improve Symptoms
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Rehabilitation
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Pain Relief
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Support in Healing/Recovery
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Stress Relief
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Other
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Well Being
Caffeine
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Date of Diagnosis
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Location
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Status
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Area of Complaint
Neck
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Upper Back
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Mid Back
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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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Right Leg
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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 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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Headaches
Headaches
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Migraines
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Other Headaches
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Neurological
Tingling
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Loss of Sensation
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Brain Injury
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Parkinsons
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Chronic Pain Disorder
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Multiple Sclerosis
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Sciatic Pain
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Shingles
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Seizure Disorder
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Cerebral Palsy
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Vertebral and Spinal Cord Injury
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Herniated Disc
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Huntington Disease
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Numbness
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Other Neurological
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Musculoskeletal
Chronic Fatigue Syndrome
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Whiplash
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Fracture
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Gout
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Joint Stiffness / Swelling
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Arthritis
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Muscular Dystrophy
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Sinus Problems
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Artificial Joints / Special Equipment
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Degenerative Disk Disease
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Osteoarthritis
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Spasms / Cramps
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Fibromyalgia
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Plantar Fasciitis
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Strain/Sprain
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Joint Injury
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Osteoporosis
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Jaw Pain (TMJD)
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Dislocation
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Other Musculoskeletal
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Skin
Skin Irritations
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Bruise Easily
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Skin Conditions
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Miscellaneous
Surgical Pins or Wire
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
Weeks Pregnant
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Twins or More
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High Risk Pregnancy
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Massage Goals
Date of Last Massage
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Light Pressure Preferred
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Medium Pressure Preferred
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Deep Pressure Preferred
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Which best describes what you are experiencing
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Ache
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Tension
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Disabling
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Discomfort
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Other
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Allergy
Sensitive to scents/essential oils
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Latex
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Other Allergies
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Emotion / Mood
PTSD
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Anxiety
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Depression
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