Confidential Medical History
Date:___________________
Name:__________________________ Address:_____________________
Phone[c]: ________________________ ________________________
Other:_________________________ Email:_______________________
Gender: M___ F___ Height:____ Weight:____ Date of birth:_________
Name of Spouse:_______________ Occupation:____________________
Have you ever had a professional massage before? Yes___ No___
Date of last session: ____________ Referred by:____________________
What do you want from today's session? __________________________
________________________________________________
Where so you hold tension? __________________________
List types of exercise: ______________________________
_______________________________________________
What medications are you taking?______________________
_________________________________________________
Have you ever had an operation[s]? [Please describe]_______________
____________________________________________________
____________________________________________________
Broken bone[s]? ________________________________________
______________________________________________________
A serious accident? _______________________________________
______________________________________________________
What are your present symptoms?___________________________
_______________________________________________________
How did they develop? _____________________________________
List diagnosis [if known]________________________________________
Current treatments:____________________________________________
__________________________________________________
Have x-rays or MRI been taken? ____ When did condition start? _____
What are you’re Pain Levels on a 1 to 10 scale with 10 being the worst pain you have ever felt: 1-—2----3----4----5----6----7----8----9----10
Is it getting worse? Y ___ N ___ Constant____ Comes & goes______
Is it interfering with your: Work _____ Sleep ____ Daily routine ____
Standing ____ Sitting ____ Walking ____ Lying down ____
Have you had this issue before? _______ When? ___________________
Have you have seen other health professionals for treatment of your current problem: ________________________________________
Please check any conditions that have applied to you in the past 5 years.
___Chronic fatigue ___Rheumatoid A. ___Auto-immune
___Allergies ___Arthritis [other] ___Arteriosclerosis
___Anemia ___Aneurysm ___Allergies to fragrances
___Aids or HIV ___Asthma ___Heart condition
___Edema ___Cancer ___Arrhythmia
___Depression ___Constipation Minor:__________________
___ Ears ringing ___Emphysema Major:__________________
___Fainting ___Headaches___Dizziness / loss of balance
___Fatigue ___Migraines ___ Shortness of Breathe
___Carpel tunnel ___Inflammation ___Blood pressure: high/ low
___Hypoglycemia ___Nervousness ___Liver/Pancreas/Kidney
___Muscle spasm ___Menstrual pain ___ Goiter/thyroid; high/ low
___Paralysis ___PMS ___ Numbness/Pins & needles ___Rashes/Shingles
___Sciatica ___Painful/Swollen joint
___Scoliosis ___Indigestion ___ Phlebitis/ Thrombosis
___TB ___TMJ Dys/Dental ___ Cold hands/feet
___Twitching ___Sinus Problems ___Varicose veins
___ Ulcers ___Stomach ___Over/ Under Weight
___ Hernia ___Light bothers eyes ___Polyvagal injury
___Bursitis or ___Sleeping problems ___concussion
tendonitis ___COVID _____________________
Have you had a Covid vacination? Yes___ no___
Because a massage therapist must be aware of any existing physical conditions that I have, I have listed all my known medical and physical limitations; and I will inform my therapist of any changes in my physical health.
I understand that the massage therapist neither diagnoses illness, disease or any other medical, physical or mental disorder nor performs any spinal manipulations. I am responsible for consulting a qualified physician for any ailment that I may have.
I agree to pay for all services at the time of service unless prior arrangements have been made. I understand the information contained herein is privileged and confidential.
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[signature] [date]