HEALTH FORM

Last Name _________________First Name_________________ Date_________

Date of Birth __________________Weight_____________Height_________________

Address _______________________________________________ Phone________

E mail address ____________________________________________ Cell phone ____

Emergency Contact________________________________________ Phone________

Have you ever received massage therapy before?

Health information Please check all that apply

Primary Care Physician__________________________________ Phone_________

 In recent years have you had surgery, broken bones, sprains or strains?

 Any lingering effects from the above?

Do you frequently experience:  stress, headaches, neck or back pain?

 tension or soreness in a specific area?

 numbness or stabbing pains?

 chronic, ongoing pain?

 do activities affect the pain?

 Allergies, specifically topical  Blood clots  Autoimmune condition

 High blood pressure  Diabetes  Contagious condition

 Cardiac/ circulatory problems  Epilepsy  Pregnancy

 Varicose veins  Arthritis

Are you taking prescription drugs? If yes, please list.

Note: Please consult your primary care physician before receiving a massage if you have any

pre-existing medical conditions. Some examples of contraindications are severe high blood pressure,

kidney or heart abnormalities, phlebitis, severe varicose veins, embolus, HIV (especially with open sores),

osteoporosis, severe scoliosis, high risk pregnancy, psychosis, liver or kidney problems, recent fever and

any other condition which you may feel unsure about.

Signed: ____________________________________________ Date: __________