Health History Form

Please complete this 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.











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.).





Specific Medical Conditions: If you ever had any of the following conditions, please indicate whether was past or is current and add any comments that might further clarify.

















Consent for Care: It is my choice to receive massage therapy and I am aware of the benefits and the risks. 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.