HH Form

Health History Form
For your information: the information requested below will assist us in treating you safely and optimize your health outcomes, and that not providing
such could lead to unforeseen risks, consequences and side effects. Feel free to ask any questions, raise any concerns or discuss further about the
information being requested. Please note that all information provided below will be kept confidential unless allowed or required by law, this includes
any other documentation related for up to 10 years. Your written permission will be required to release any information. If your health status changes,
please let us know and we will update this health form. This form will be updated yearly. If our position here changes, we will give advance notice
and ensure any documentation will be transferred and/or stored to your wishes.
Name: Phone #:
Address:
Occupation: Date of Birth:
Have you received massage therapy before? Yes No
Did a health care practitioner refer you for massage therapy? Yes No
How did you hear about us?
If yes, please provide their name and address:
Primary Care Physician: Phone #:
Address:
Are you currently receiving treatment from another health care professional: Yes No
If yes, whom and for what?
May I ask for additional information from other health professionals in your circle of care? Yes No
How is your health?
Please indicate the conditions you are experiencing or have experienced, timing, along with any family history below
Cardiovascular Head and Neck Do you have any other medical
 High Blood Pressure  Headaches conditions or sensitivities (e.g. digestive,
 Low Blood Pressure  Migraines scar, etc.)? ________________________
 Chronic Congestive Heart Failure  Vision problem or loss __________________________________
 Heart Attack If yes, what kind? __________________________________
 Phlebitis/Varicose Veins  Ear problems __________________________________
 Stroke/CVA  Hearing problems or loss Current Medications and the Condition
 Atherosclerosis If yes, which ear? it’s for: ___________________________
 Heart Disease Orthopedic __________________________________
Respiratory  Arthritis __________________________________
 Chronic Cough  Osteoporosis __________________________________
 Shortness of Breath  Fracture __________________________________
 Bronchitis If yes, where? Surgical History: ___________________
 Asthma If yes, how? __________________________________
 Emphysema If yes, when? __________________________________
 Smoker/Vaper  Sprain or Strain __________________________________
If yes, how much? If yes, where? __________________________________
Women If yes, how? Do you have any internal pins, wires,
 Pregnancy If yes, when? artificial joints or special equipment?
When? Other Conditions __________________________________
How?  Loss of sensation __________________________________
 Gynecological condition If yes, where? __________________________________
If yes, what?  Skin Condition __________________________________
Infections If yes, what is it? What is your general health status?
 Hepatitis  Diabetes __________________________________
If yes, what kind?  Allergies What is the reason you are seeking
 TB If yes, what? massage therapy? Please locate.
 HIV/AIDS If yes, reaction type: __________________________________
 Herpes  Epilepsy __________________________________
 Cancer __________________________________
If yes, state details __________________________________
 Mental Health
If yes, what?
Client Consent:
The information provided is accurate, complete and up-to-date. It is the Clients
personal responsibility to keep the Registered Massage Therapist updated on their
prudent information, medical history and immediate family association along with
any future changes to the above.
Date: _________________________________________________________
Client Signature: _______________________________________________

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Health History Form

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