Massage Therapy Health History Form

Health History

The information requested below will assist us in treating you safely. Please feel free to ask any questions about the information being requested. Please note that all information provided below will be kept confidential unless allowed or required by law. Your permission will be required to release any information, and you have the right to give, withhold or withdraw your consent to collect, use or disclose any personal health information at any time.

Primary reason(s) for seeking massage therapy (e.g. relaxation, wellbeing, rehabilitation, pain relief, injury):

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Please describe your pain, how it may affect activities of daily living, whether it is constant or sporadic and if there is anything you do that makes it better or worse.

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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, joint sprains, dislocation, pins/plates, plantar fasciitis):

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Heart or circulation concerns (e.g. high blood pressure, diabetes, migraines, fainting, clotting disorders, arrhythmias):

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Neurological symptoms or conditions (e.g. sciatica, 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, rash, psoriasis, sensitive skin, plantar warts):

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Are you aware of any illness, disease or infection that you have, that may be contagious or pose a risk to those in close/physical contact with you. Examples: Cold/Flu, hives(Poison ivy), blisters(Shingles/Herpes flareup), open wound, athletes foot etc.:

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

Yes

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

Yes

Cancer Treatment History:

Have you been diagnosed with cancer or received or are currently receiving cancer treatment (e.g., chemotherapy, surgery, radiation)?

Yes

If yes, please describe any symptoms this may be causing you, as massage therapy can help address many of the symptoms related to cancer and cancer treatments:

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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?

Yes

Are you high-risk or have any additional information or concerns related to pregnancy? (e.g. Uterine fibroids, Preeclampsia):

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