ࡱ>  @ vbjbjPP :::h T<<`QSSSSSS$2Rnwwqqq|QqQqqq  P/e_mqQ0q%|qqqwwHealth History Form An accurate health history ensures that it is safe for you to receive massage therapy and helps the therapist determine the best possible way to address your needs during the session. All answers to these questions will remain confidential. We appreciate you taking the time to complete this questionnaire. Thank you. Personal Information (Please print) Name: _________________________________________________________________ Address: _______________________________________________________________ City: ________________________________ Postal Code: _______________________ Daytime Phone: ______________________ Evening Phone: _____________________ Birth Date: ________________________ Email: ______________________________ Emergency Contact Name: __________________________ Phone: ______________ Have you had a massage before? Yes No Current Medications: ____________________________________________________ ______________________________________________________________________ Previous Major Illnesses, Operations: _______________________________________ ______________________________________________________________________ Accidents (please give dates): _____________________________________________ ______________________________________________________________________ Other Medical Conditions (ie: diabetes, hemophilia): ___________________________ ______________________________________________________________________ Please specify allergies: ___________________________________________________ _______________________________________________________________________ Many of our products contain nut oils or milk products; we can make accommodations if you require them. The massage menu outlines the types of oils and additives used. Please also indicate if there are any essential oils you are allergic to. Please indicate all conditions you have experienced. Mark C for current or P for past: Joint/Soft Tissue Discomfort: ___ Arms ___ Upper Back ___ Middle Back ___ Lower Back ___ Degenerative Discs ___ Feet ___ Hands ___ Hips ___ Jaw ___ Knees ___ Legs ___ Neck ___ Shoulders ___ Osteo-Arthritis ___ Rheumatoid Arthritis ___ Sciatica ___ Limitation of Movement In which joint(s)? ______________________________________ Skin: ___ Rashes ___ Itching ___ Bruise Easily ___ Dryness ___ Boils General Symptoms: ___ Fainting ___ Dizziness (Continued on Reverse) Health History General Symptoms (continued): ___ Sudden Weight Loss/Gain ___ Numbness ___ Tingling ___ Paralysis ___ Headaches (tension) ___ Migraines Cardiovascular: ___ High Blood Pressure ___ Low Blood Pressure ___ Heart Disease ___ Heart Attack ___ Phlebitis ___ Stroke / CVA ___ Heart murmur ___ Palpitations ___ Varicose Veins ___ Swelling of Ankles ___ Poor Circulation Infectious: ___ Hepatitis ___ Tuberculosis ___ Athletes Foot Other: ______________ Eye, Ear, Nose, Throat: ___ Frequent Colds ___ Hearing Loss ___ Sinus Infection Respiratory: ___ Chronic Cough ___ Bronchitis ___ Asthma ___ Difficulty Breathing ___ Smoking ___ Emphysema ___ Pneumonia Digestive: ___ Constipation ___ Nausea ___ Ulcer Reproductive: ___ Pregnant Due Date: _______ ____________________________________________________________________________________ Please specify any areas of concern that you would like the massage therapist to address during the session: ________________________________________________________________________________________ ________________________________________________________________________________________ If you are feeling discomfort in the areas specified (above), please indicate how long youve had these symptoms: ________________________________________________________________________________________ ________________________________________________________________________________________ If applicable, what aggravates your condition? __________________________________________________ ________________________________________________________________________________________ Is there anything that you have done that provided some relief: _________________________________________________________________________________________ _________________________________________________________________________________________ Please indicate areas where you are experiencing discomfort by drawing an X on the diagrams below:  By signing below you are acknowledging that the information you have provided is true and accurate. 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