Massage Therapy Health History Form Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4 W: www.greenbasehealth.com E: [email protected] T: 519-574-5151 The information requested below will assist in treating you safely and effectively. Feel free to ask questions of the information being requested and note that all information will be kept confidential unless you grant us written permission to share it if needed. Name: ____________________________________________ Date of Birth: __________________________ Address: __________________________________________________________________________________ Primary Phone #: __________________________________ Email: _________________________________________________________ Would you prefer to be contacted by Phone ⃝ or Email ⃝ Primary Care Physician Name and Address: ____________________________________________________________________________ Emergency Contact: _____________________________________________ Phone: __________________________________________ What is your Occupation? __________________________________________________________________________________________ How did you hear about us? ________________________________________________________________________________________ Check if you would like to receive our online Newsletter ⃝ Please indicate below conditions your are experiencing or have experienced: Cadiovascular ⃝ High Blood Pressure ⃝ Low Blood Pressure ⃝ Chest Pain/ Angina ⃝ Chronic Congestive Heart Failure ⃝ Heart Attack ⃝ Phlebitis/ Varicose Veins ⃝ Stroke/CVA ⃝ Pacemaker or similar device ⃝ Heart Disease Is there a family history of the above? ______ Head and Neck ⃝ Headaches Frequency ___________ ⃝ Migraines Frequency ___________ ⃝ Dizziness ⃝ Brain Injury ⃝ Vision Problems ⃝ Vision Loss ⃝ Ear Problems ⃝ Hearing Loss ⃝ Sinus Pain Respiratory ⃝ Chronic Cough ⃝ Asthma ⃝ Shortness of Breath ⃝ Bronchitis ⃝ Emphysema Is there a family history of the above? ______ Other Conditions ⃝ Numbness/ Loss of Sensation ⃝ Bruise Easily ⃝ Light Headed ⃝ Fatigue ⃝ Fibromyalgia ⃝ Edema ⃝ Osteoarthritis ⃝ Rheumatoid Arthritis ⃝ Osteoporosis ⃝ Digestive Problems ⃝ IBS/Crohns/Colitis ⃝ Nausea ⃝ Ulcer ⃝ Diabetes ⃝ Epilepsy ⃝ Cancer: _____________ ⃝ Mental Illness:_______________ Infections ⃝ Hepatitis ⃝ Skin Conditions ⃝ Rash ⃝ TB ⃝ HIV ⃝ Herpes ⃝ Warts Other: ______________ 1 Allergies: ________________________________ Pins, wires, plates or artificial joints? Please Specify:____________________________ ________________________________________ Do you Smoke?: YES ⃝ NO ⃝ Do you exercise?: YES ⃝ NO ⃝ Other Conditions: _________________________ ________________________________________ Overall, how is your general Health? ________________________________________ Women Only Are you Pregnant? YES ⃝ NO ⃝ Due Date: ________________________________ Menstrual Problems or Conditions? _________________________________________ _________________________________________ Date of Initial Health History: Update 1: _______________ Update 2: _______________ OFFICE USE Update 3: _______________ ONLY Update 4: _______________ Have you had massage therapy in the past? Yes ⃝ No ⃝ When was your last treatment? ___________________________________ What’s your reason for having a massage today?________________________________________________________________________ How did this condition star? ________________________________________________________________________________________ Do you have a goal or outcome you want to see with your massage therapy treatment? ________________________________________ On the diagram below, please indicate areas of concern (pain, tension, inflammation, reduced range of motion, etc) Have you experienced any injuries, surgeries or accidents? Please list them along with the approximate time they occurred and any treatment you received: __________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Have you ever been hospitalized? If so, please indicate when and why: ________________________________________________________ __________________________________________________________________________________________________________________ If you are currently on any supplements or medication please indicate what they are and the reason you take them: ___________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ I, __________________________________ ,declare that the above information is correct and if, in the future, my health information should change, I acknowledge that it is my responsibility to inform Robyn Ellis RMT either before or at my next scheduled appointment. I understand that all the information I have given on this form is confidential and I have to right to ask questions regarding my massage treatment and that I have the right to stop or modify my treatment at any time. I also understand that a minimum of 24 hours notice is required to avoid missed/cancelled appointment fees ($30) if I need to cancel or reschedule my appointment. Signature: ______________________________________Date:________________________ 2 Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4 W: www.greenbasehealth.com E: [email protected] T: 519-574-5151