Massage Health History Form

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Confidential Massage Health History Form

* Indicates required field

Name *

First

Last

Email *

Phone number *

Address *

Date of birth *

Emergency name and number *

Occupation *

Recreational activities *

How did you hear about us? *

Have you had a massage before? *

Do you have difficulty lying on your back or front? *

Choose any conditions that apply *

Heart / circulation problems Varicose veins Phlebitis Infectious disease Rash / athletes foot Allergies Diabetes Pregnacy Headaches or migraines

Choose any conditions that apply *

Cancer / tumours Asthma Hernias Abdominal problems Arthritis Numbness or tingling Muscle / bone injuries Muscle / joint pain Chronic pain

Choose any conditions that apply *

Vision problems / contact lenses Hearing problems Fatigue Depression Seizures Stroke Skin disorders Previous car accident Accident / trauma

Other conditions or injuries past or present *

Current medications *

Recent surgeries *

Consent is required to massage each part of the body. Please indicate which areas you would like included.

Please choose 1 or more areas *

Back Buttocks Legs Feet Arms Chest

I understand that:
In accordance with the scope of practice of a massage therapist as well as adhering to regulatory and statutory
requirements it is not the role of the massage therapist to diagnose injury or illness, or prescribe medication.

Please write your name and date below to confirm that the information you have provided is correct to the best of your knowledge.

Name *

Date *

Message for therapist *

Submit Form

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Pre-Exercise Form

Home
- What Is An Exercise Physiologist?
Services
- Bootcamp Alternative >
  - Pre-Exercise Form
- Relaxation Massage
Get In Touch!
Fitness Vlog
- Free Stuff! >
Members Area