Health History Form Today's Date MM slash DD slash YYYY Name First Last Date of Birth MM slash DD slash YYYY Email Address Street Address City State / Province / Region ZIP / Postal Code PhoneOccupationPlease provide your Emergency Contact, Relationship, and Phone numberName of Primary Care Provider?Current Medical Conditions?How Did You Hear About Us? Google Search Social Media Friend Referral Referred ByWhen Was Your Last Massage? 0-6 Months 6 Months - 1 Year Over 1 Year Benefits You Are Hoping To Gain Through Massage?Medical InformationToday's Primary Concern?Level of Discomfort? Mild Moderate Severe Duration of Discomfort Constant Intermittent Other When did you first notice the discomfort? 0-6 Months 6 Months - 1 Year Over 1 Year What activities cause discomfort?What helps relieve the discomfort?Other areas of concern?Please check all the following that apply to you:(Required) Heart Problems Blood Pressure Problems Skin Problems Spinal / Back Problems Digestive / Intestinal Problems Varicose Veins Breathing Problems Immune Deficiency Problems Sleep Problems Frequent Headaches Cancer-Related Problems Jaw Pain / Sinus / Dental Problems Hip or Leg Problems Mental / Emotional Sress Seizures / Epilepsy Diabetes Grief / Depression Allergies Surgeries Accidents Dentures Hearing Aids Prosthesis Pacemaker Pregnant Tendency to be hot Tendency to be cold Wear Contacts Have Implants If Pregnant, how many weeks?What Kind Of Allergies?What Surgeries?What Accidents?Average Daily Intake of Tobacco?Average Daily Intake of Caffeine?Average Daily Intake of Alcohol?Other Conditions?Any areas of the body sensitive to touch or therapist should avoid?What Do You Do For Exercise or Stress Reducing Activities?Current Medications, Supplements or Complimentary Therapies (ie, Chiropractic Care)Consent(Required) I agree to the informed consent policy.I understand that massage therapy is not a substitute for medical care and that any information provided by the therapist is for educational purposes only and is not diagnostic or prescriptive in nature. Because a massage therapist must be aware of existing physical and mental conditions, I have stated all my known medical conditions and taken it upon myself to keep the massage therapist updated on my physical and mental health. It is also understood 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. I understand that I will be charged for appointments not canceled 24 hours in advance.