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Microsoft word - health information sheet.doc

CLIENT HEALTH INFORMATION SHEET
PERSONAL DATA:
Name: ________________________________ Date: ______________________________
Birthday: ______________________________ Phone (home):_______________________
Address: _______________________________ Phone (cell): ________________________
City/State/Zip: ________________________________________________________________
Primary Health Care Provider: _____________________ Phone: ______________________
Permission to consult with primary provider? _______ Yes _______ No
Who referred you to this office? __________________________________________________
Advertisement: _______ Sign: _______ Other: _______
MASSAGE HISTORY/TREATMENT INFORMATION
* Have you ever received a professional massage? _____ Yes _____ No
* Preferred massage treatment product. ____ Lotion ____ Oil ____ Aromatherapy
* What are your intentions/expectations for this visit? __________________________
______________________________________________________________________
* What type of pressure do you prefer? _____ Light _____ Medium _____ Deep
* Please check the areas of your body that you give permission to receive massage:
__ Back __ Legs __ Arms __ Neck __ Head __ Face __ Buttocks __ Abdomen
CURRENT MAJOR COMPLAINT INFORMATION
(If you do not have current health concerns, please go to health history section)
* Present symptoms: What is your major complaint or condition that you want to improve?
______________________________________________________________
_______________________________________________________________________
* When did you first notice major complaints? _________________________________
* What activities aggravate the condition? ____________________________________
* What activities alleviate the condition? _____________________________________
* Is this condition getting progressively worse? _____ Yes _____ No
Please explain __________________________________________________________
* Does this condition interfere with:
Work? ___ Yes ___ No Sleep? ___ Yes ___ No Daily routine? ___Yes ___ No
Please explain: _________________________________________________________
* What have you done to get relief? __________________________________________
* Has there been a medical diagnosis? ___ Yes ___ No
If so, by whom? ________________________________________________________
Please explain __________________________________________________________
HEALTH HISTORY
* Are you now under medical/therapeutic treatment? ___ Yes ___ No
If yes, for what condition? _______________________________________________
* List any medications (including aspirin) and nutritional supplements you are taking:
______________________________________________________________________
* List stress reduction and exercise activities. Include frequency: _________________
______________________________________________________________________
* Please list (date and description) any accidents or operations: ___________________
______________________________________________________________________
MUSCULO-SKELETAL SKIN
___ Bone or joint disease ______________________ ___ Allergies __________________
___ Tendonitis ______________________________ ___ Rashes ____________________
___ Bursitis ________________________________ ___ Athlete’s foot _______________
___ Broken/fractured bones ____________________ ___ Warts ____________________
___ Arthritis ________________________________ ___ Other _____________________
___ Sprains/strains ___________________________
___ Low back,hip,leg pain _____________________ DIGESTIVE
___ Neck,shoulder,arm pain ____________________ ___ Constipation
___ Headaches/head injuries ___________________ ___ Gas/bloating
___ Spasms/cramps __________________________ ___ Diverticulitis
___ Jaw pain/ TMJ ___________________________ ___ Irritable bowel syndrome ____
___ Lupus _________________________________ ___ Other _____________________
___ Other __________________________________

CIRCULATORY NERVOUS SYSTEM
___ Heart condition __________________________ ___ Herpes/shingles ____________
___ Varicose veins ___________________________ ___ Numbness/tingling __________
___ Blood clots _____________________________ ___ Chronic pain _______________
___ High blood pressure ______________________ ___ Fatigue ___________________
___ Low blood pressure ______________________ ___ Sleep disorders _____________
___ Lymphedema ___________________________ ___ Other
___ Breathing difficulty _______________________
___ Sinus problems __________________________ REPRODUCTIVE
___ Allergies _______________________________ ___ Pregnant? Stage ____________
___ Other __________________________________ ___ PMS _____________________
AUTO IMMUNE/INFECTIOUS DISEASE OTHER
___ Fibromyalgia ___________________________ ___ Cancer/tumors _____________
___ Chronic fatigue _________________________ ___ Diabetes __________________
___ Rheumatoid arthritis _____________________ ___ Eating disorders ____________
___ Lupus ________________________________ ___ Depression ________________
___ Epstien Barr ____________________________ ___ Drug/alcohol addiction _______
___ Other _________________________________ ___ Nicotine/caffeine addiction ____
It is my choice to receive massage treatment. I realize that the treatment is being given for the
well-being of my body and mind. This includes stress reduction, relief from muscular tension,
spasm or pain, or for increasing circulation or energy flow. I agree to communicate with my
practitioner any time that I feel like my well-being is being compromised.
I understand that massage practitioners do not diagnose illness, disease or any physical or mental
disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust
manipulations. I acknowledge that massage is not a substitute for medical examination or
diagnosis, and that it is recommended that I see a primary health care provider for that service.
I have stated all medical conditions that I am aware of and will update the massage practitioner
of any changes in my health.
Signature: ____________________________________ Date: _______________________

Source: http://www.teamapproach.biz/wp-content/uploads/2011/10/Health-Information-Sheet1.pdf

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