Sollievo Massage and Bodywork

Sollievo  |  2285 Massachusetts Ave  |  Cambridge, MA 02140
Book Your Appointment! Click Here or Call (617)354.3082

Massage Therapy Health History Form

Please complete the following form. This information will help your practitioner to assess your needs before any hands-on work is done and to provide you with the highest quality of care. Any information that is provided will be kept confidential.

First Name *
Last Name *
Address *
City *
State *
Zip *
Best number to reach you *
Email *
Date of Birth *
Do you wish to fill out the complete form now?
Yes No
Occupation
Contact Person In Case of Emergency:
Full Name:
Relationship:
Phone:
Are you currently under the care of a Primary Care Physician or other Health Practitioner for a particular condition?
Yes No
For what condition(s)?
Do we have your permission to contact him/her?
Yes No
Physician's Full Name:
Physician's Phone:
Should you see multiple practitioners here, do we have your permission to confer with each other regarding your health program?
Yes No
Medical Insurance Carrier:
Medical Insurance Carrier Phone:
Current Medications:
Do you wear contact lenses?
Yes No
Your Level of Stress:
(10 being the highest)
Do you exercise?
Yes No
How Often?
What Type?
Other Activities:
(i.e. walking to work)
Have you ever had a massage before?
Yes No
Likes:
Dislikes:
General Symptoms: Please indicate whether or not you are experiencing any of the following general symptoms at the present time and add any comments that might further clarify (i.e. locations on the body, names of conditions, etc.).
Symptoms:
Comments:
Swelling
Pain or Tenderness
Numbness or Tingling
Site of Infection
Specific Medical Conditions: please indicate whether you have or have had any of the following conditions, whether past or present. This helps us modify your treatment if necessary.
Condition:
Comments:
Skin
(i.e. rashes, itching, etc.)
Past Present
Allergies
Past Present
Cancers or Tumors
Past Present
Cardiovascular
(i.e. stroke, Heart Attack, etc.)
Past Present
Gastrointestinal
Past Present
Liver or Kidney
Past Present
Respiratory/Lung
Past Present
Diabetes
Past Present
Arthritis
Past Present
Pregnancy
Past Present
Injuries
(i.e. fractures, etc.)
Past Present
Headaches
Past Present
Surgeries
Past Present
Other
Past Present
Are any of the above conditions due to an accident?
Yes No
Please Explain:
Is there anything else that you feel would be helpful for the practitioner to know?
Yes No
Please Explain:
How did you hear about us?
Would you like to receive email notifications regarding new services, discounts, promotions and more?
Check all that apply.



Consent for Care: It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.
  I Agree.
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"Sollievo is an oasis in the middle of the city. It's a great, quiet atmosphere, with no distraction – I couldn't hear a thing outside the treatment room. Every detail here is first class. Sollievo has brought to North Cambridge something truly unique in bodywork."
– RL, Cambridge area senior

Sollievo - Massage and Bodywork

2285 Massachusetts Ave Cambridge, MA 02140

Conveniently located near Porter, Davis & Harvard Square and across the river from Boston.

Phone: (617)354.3082
Fax: (617) 354.3085
Email: info@sollievo.org

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