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Transcript
Health History Form
Meagan Michalski, RMT
An accurate health history is important to ensure that it is safe for you to receive a massage treatment. If your health status changes in the
future, please inform you therapist. All information gathered for this treatment is confidential except as required or allowed by law or
except to facilitate diagnosis (assessment) or treatment. You will be asked to provide written authorization for release of any information.
PERSONAL INFORMATION
Name: _____________________________________________________
Address: __________________________________________________
City: ___________________________ Postal Code: _____________
Today’s Date: ______________________________________
Birthdate: __________________________________________
Phone Number: ____________________________________
Business Number: _________________________________
Height (inches): _____________ Weight (lbs): _____________
Who referred you? _______________________________________
Emergency Contact: _______________________________
Primary Physician: _______________________________________
Emergency Contact #: _____________________________
Physician Address: _______________________________________
Physician Phone Number: _______________________________
Other Health Care Practitioners:
Chiropractor Physiotherapist Naturopath
Other: _________________
General Health Status:
POOR
FAIR
GOOD
EXCELLENT
Occupation: _______________________________________________
Recreational Activities: ____________________________
Primary Occupation Activities: __________________________________________________________________
Primary Complaint: _______________________________________________________________________________
Pain Scale: 0
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HEALTH HISTORY
Please indicate all current/ongoing (C/O) and past conditions you have experienced
Head/Neck
C/O
Past
Whiplash
☐
☐
Headaches
☐
☐
Migraine
☐
☐
Concussion
☐
☐
Ringing in the Ears
☐
☐
Hearing Loss
☐
☐
Vision Problems
☐
☐
Brain Injury
☐
☐
TMJ (Jaw Pain)
☐
☐
Other: __________________________________
Respiratory/Lungs
C/O
Past
Digestive
C/O
Past
Asthma
☐
☐
Constipation
☐
☐
Bronchitis
☐
☐
Diarrhea
☐
☐
Emphysema
☐
☐
Crohn’s Disease
☐
☐
Pneumonia
☐
☐
Irritable Bowel Syndrome☐
☐
Shortness of Breath
☐
☐
Ulcers
☐
☐
Sinusitis
☐
☐
Diverticulitis
☐
☐
Frequent Colds
☐
☐
Nausea
☐
☐
Recurrent Lung Infection ☐
☐
Chronic Cough
☐
☐
Family History of Above: _________________ Other:_____________________________________
Other: __________________________________________
Cardiovascular
C/O
Past
High Blood Pressure ____/_____
☐
☐
Low Blood Pressure ____/_____
☐
☐
Heart Attack
☐
☐
Chronic Congestive Heart Failure ☐
☐
Chest Pain/Angina
☐
☐
Stroke
☐
☐
Pace Maker or Similar Device
☐
☐
Phlebitis
☐
☐
Hemophilia
☐
☐
Heart Disease
☐
☐
Poor Circulation
☐
☐
Congestive Heart Failure
☐
☐
Family History of Above: __________________________
Other: _______________________________________________
Nervous System
Spinal Cord Injury
Numbness/Tingling
Sensory Change/Loss
Sciatica
TOS
Seizures
Multiple Sclerosis
Cerebral Palsy
Epilepsy
Carpal Tunnel
Muscular Dystrophy
C/O
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Past
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Other: ____________________________________
Infections
C/O
Hepatitis
☐
Type: ___________________
Infectious Skin ☐
Conditions
☐
TB
☐
HIV
☐
Past
☐
☐
☐
☐
☐
Other: ____________________________
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Disease/Condition
C/O
Past
Cancer Benign/Malignant
☐
☐
Type/Location: ____________________________
Treatment: _________________________________
Fibromyalgia
☐
☐
Chronic Fatigue Syndrome
☐
☐
Allergies
☐
☐
Diabetes (Type?) _______________
Onset: ______________________________________
Other: ______________________________________
Soft Tissue Joint Discomfort or Pain
C/O
Head/Jaw
☐
Neck
☐
Shoulder
☐
Arm
☐
Wrist/Hand
☐
Back
☐
Hips
☐
Legs
☐
Knees
☐
Ankles/Feet
☐
Tendonitis
☐
Strain/Sprain
☐
Poor Posture
☐
Other: ___________________________________________
Skin
C/O
Past
Eczema
☐
☐
Dermatitis
☐
☐
Acne
☐
☐
Frostbite
☐
☐
Psoriasis
☐
☐
Sensitive Skin ☐
☐
Rash/Eruptions ☐
☐
Cold Sores
☐
☐
Herpes
☐
☐
Other: ___________________________
Past
Bone/Joint
C/O
Past
Dislocation
☐
☐
Fracture
☐
☐
Arthritis (RA/OA)
☐
☐
Family History of Arthritis: _______________
Degenerative Disc
☐
☐
Disease
Prolapsed/Herniated
☐
☐
Disc
Other: _______________________________________
Women Only
C/O
Past
Pregnancy
☐
☐
Vaginal Birth/Abortion ☐
☐
Weeks Pregnant: ___________________
# of Children (not including this pregnancy) ________________
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Other: _________________________________
Current medication or supplements and what condition do your medicine/supplements treat: _____________________________________
_________________________________________________________________________________________________________________________________________________
Surgical operations or Hospitalizations (please indicate date of occurrence): _________________________________________________________
_________________________________________________________________________________________________________________________________________________
Major injuries/accidents including fractures (please indicate date of occurrence): ___________________________________________________
_________________________________________________________________________________________________________________________________________________
Of special note: (pins, wires, plates, artificial joints, etc.) Please explain: _______________________________________________________________
_________________________________________________________________________________________________________________________________________________
List any areas that you do NOT want treated: _____________________________________________________________________________________________
Are you physically active?
Yes ☐ No ☐
How often and Type? _______________________________
Previous Massage Experience
Yes ☐ No ☐
Good Sleeping Habits
Yes ☐ No ☐
Regular Eating Habits
Yes ☐ No ☐
Stress Levels
High ☐
Medium ☐
PLEASE CIRCLE CURRENT
SYMPTOMATIC AREAS YOU WANT
TREATED
Low ☐
Date: ________________________________________________________
Client Signature: ____________________________________________
Therapist Signature: ________________________________________
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