Patient Forms Holistic Massotherapy Health History Form New clients should complete the form below or can access a PDF to print, fill out and bring in before their first visit. CLICK TO DOWNLOAD THE PDF Name * First Name Last Name Date of Initial Visit * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email How Did You Find Us? * Personal Referral Google Search Postcard/Flyer Drive By/Live in the Area Other (Please specify below) If other, please list how you found us. Phone (Best # for Scheduling Purposes) * (###) ### #### Date of Birth * MM DD YYYY Occupation Sports/Physical Activities/Hobbies Background Information The following information will be used to help plan safe and effective massage sessions. Please answer to the best of your knowledge. Have you ever had professional massage before? * Yes No If yes, how often? Do you have any difficulty lying on your front, back, or side? * Yes No If yes, please explain. Do you have allergic reactions to oils, lotions, ointments, or any other substances put on your skin? * Yes No If yes, please explain. Do you wear any of the following? * Please check the box for all that apply. Contact lenses Dentures Hearing aid None of the Above Do you sit for long hours at a workstation, computer, or driving? * Yes No If yes, please describe. Do you perform any repetitive movement in your work, sports, or hobby? * Yes No If yes, please describe. How do you think stress has affected your health? Please check all that apply. Muscle tension Anxiety Insomnia Irritability N/A Other If other, please describe. Is there a particular area of the body where you are experiencing tension, stiffness, or discomfort? * Yes No If yes, please identify. Do you have any particular goals in mind for this massage session? * Yes No If yes, please explain. Medical History In order to plan a massage session that is safe and effective, we need some general information about your medical history. Are you currently under medical supervision? * Yes No If yes, please explain. Are you currently taking any medication? * Yes No If yes, please list. Please check any condition listed below that applies to you: * acute/chronic disease allergies arteriosclerosis bruise easily cancer circulatory disorder contagious skin conditions cystic tumors decreased sensation diabetes epilepsy heart conditions high or low blood pressure joint disorders/artificial joints open sores or wounds osteoporosis phlebitis recent accident or injury recent surgery rheumatoid arthritis swollen glands varicose veins Comments: For women: Are you pregnant? * Yes No If yes, how many months? Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you? Signature I understand that these massage sessions are for general wellness purposes and that I should see a doctor or other appropriate health care provider for diagnosis and treatment of any suspected medical problem. Also, that it is my responsibility to keep my massage practitioner informed of any changes in my health, and any medications that I may begin to take in the future. Digital Acknowledgement * Please type your name in the field below to signify your electronic signature. Date Signed * MM DD YYYY Thank you!
