Health History Form

Health Information

(page 1 of 2)

Client Name: ___________________________________
Date of Birth: ____________ Gender: ____________
Address: _________________________________________________________________________________ Phone: _______________________________________ Email: ___________________________________ Referred by: ___________________________________
Emergency contact: _____________________________ Phone: ___________________________________ Physician/Health-care Provider name: __________________________ Phone: ____________________
Is this bodywork medically necessary (is it for a medical condition, injury, surgery)? Yes ☐ No ☐
Do you have a physician referral/prescription? Yes ☐ No ☐
Are you seeking insurance reimbursement? Yes ☐ No ☐ If yes, please complete the Billing Information form. Type of insurance coverage for this claim: Car Collision Worker’s Compensation Private Health

Have you ever received professional energy healing session before? Yes ☐ No ☐
What type? ___________________________________
What are your goals/expected outcomes for receiving this session? _________________________________________________________________________________________ _________________________________________________________________________________________

How do you feel today? ______________________________________________________________________

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.): ______________________________________________________________________________________________ ______________________________________________________________________________________________

Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes No Explain: ______________________________________________________________________________________________ ______________________________________________________________________________________________

List the medications you currently take: ______________________________________________________________________________________________ ______________________________________________________________________________________________

Are you wearing contacts? Are you wearing dentures? Are you wearing a hairpiece? Are you pregnant?

Yes ☐ No ☐                          Yes ☐ No ☐                            Yes ☐ No ☐                             Yes ☐ No ☐

Date: ____________

 

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment? ______________________________________________________________________________________________ Circle any of the following health conditions that you currently have (If you are unsure, please ask):
blood clots, infections, congestive heart failure, contagious diseases, pitted edema
Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past Current Past

Muscle or joint pain _____________________________________ Muscle or joint stiffness _____________________________________ Numbness or tingling _____________________________________ Swelling _____________________________________

Bruise easily _____________________________________
Sensitive to touch/pressure _____________________________________
High/Low blood pressure _____________________________________
Stroke, heart attack _____________________________________
Varicose veins _____________________________________
Shortness of breath, asthma _____________________________________
Cancer _____________________________________
Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________ Epilepsy, seizures _____________________________________
Headaches, Migraines _____________________________________
Dizziness, ringing in the ears _____________________________________
Digestive conditions (e.g. Crohn’s, IBS) _____________________________________
Gas, bloating, constipation _____________________________________
Kidney disease, infection _____________________________________
Arthritis (rheumatoid, osteoarthritis) _____________________________________ Osteoporosis, degenerative spine/disk _____________________________________
Scoliosis _____________________________________
Broken bones _____________________________________
Allergies _____________________________________
Diabetes _____________________________________
Endocrine/thyroid conditions _____________________________________
Depression, anxiety _____________________________________
Memory Loss, confusion, easily overwhelmed _____________________________________

Comments: ______________________________________________________________________________________________ ______________________________________________________________________________________________

Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Client Signature: _____________________________________________________________ Date: ____________ Parent or Guardian Signature (in case of a minor): ___________________________________ Date: ____________