Massage Health History Form

Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

Are you currently under the care of a physician?

YesNo

Please provide details

Do you have any existing medical conditions?

YesNo

Please provide details

Are you taking any medications?

YesNo

Please list medications and dosage

Have you had any surgeries in the past year?

YesNo

Please provide details

Do you have any allergies (latex, oils, lotions, etc.)?

YesNo

Please specify

Have you ever experienced any of the following conditions?

Are you pregnant?

YesNo

How many weeks pregnant are you?

Do you have any specific areas of concern or areas you would like the massage therapist to focus on?

Is there anything else you think the massage therapist should know about your health?

Declaration:

I, the undersigned, confirm that the information provided in this form is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform the massage therapist of any changes in my health.

Date

Signature

Massage Health History Form

Client Information

Health History