Therapeutic Massage Medical History Form
Name:
Date of Birth:
Address:
State:
Zip Code:
City:
Work Phone:
Cell Phone:
Home Phone:
E-Mail:
Employer:
Occupation:
How did you hear about us?
Yes
NO
Have you had a professional massage before?
Please tell us briefly about your past
massage experiences.
Why did you make this appointment? (Stress,
Relaxation, Pain Relief, Therapy, etc.)
Please list any serious / chronic illness,
past operations, or traumatic accidents
Occasionally
Rarely
Regularly
Do you exercise?
Are you under the care of a chiropractor or other health care provider?
Yes
NO
Current Medications:
Current and Past Medical History -- Mark all that apply.
AIDS
Circulatory
Problems
Seizures
Hepatitis
Allergies
to scents
or lotions
High BP
Sinus
Current
Infection
Skin
Problems
Low BP
Diabetes
Arthritis
Osteoporosis
Spasms
/ Cramps
Fainting
Pregnant
or trying
to get
pregnant
Asthma
Stress
Flu or cold
symptoms
within last
48 hours
Back
Problems/
Injurys
Tendonitis
Recent
Fever
TMJ (Jaw
Pain)
Blood Clots
Headaches
Sciatica
Broken bones
Varicose
Veins
Heart
Disease
Scoliosis
Cancer
I understand that massage therapists DO NOT diagnose illness, disease or any other physical
or mental disease. Nothing that is said or done should be misconstructed as such. Massage
Therapy is not a substitute for medical examination &/or diagnosis.
It is my choice to receive massage therapy, and I give consent to receive treatment. Because
massage/bodywork is contraindicated (should not be done) under certain medical
conditions, I affirm that I have stated all my known medical conditions and shall take it upon
myself to keep the therapist updated on my physical health.
It is understood that any illicit or sexually remarks or advances made will result in immediate
termination of the session and I will be liable for payment in full.