Health History

HEALTH HISTORY - LIFESTYLE INTAKE
All information disclosed in this health history will remain confidential. 
Use the back if you need space.
Name: ____________________________ Date: ___/___/______ Birth date: ___/___/______
Phone: _____________________ Email: ______________________________________
Would you like to receive monthly emails with news and discounts? Yes_______ No _______
Address: Street: _______________________ City: ____________State: _____ Zip: ________
Emergency Contact: Name: _________________________ Phone: _____________________
How did you hear about me? _____________________ Referred by: _____________________
Please list any allergies or sensitivities, especially to oils, lotions, or scents, and latex:
___________________________________________________________________________________
Current Medications (Prescription and over the counter, including dose, reason for taking, and side effects):
___________________________________________________________________________________
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Do you have any ongoing or frequent pain, tension or other discomfort or dysfunction? _______________
If yes, where? _______________________________________________________________________
How often does it occur? _______________________ How severe is it? __________________________
What makes it better? _________________________________________________________________
What makes it worse? _________________________________________________________________
Women: Are you pregnant? ________ Due Date: ________ Complications? _______________________
Do you consider yourself stressed? ________________ What causes your stress? ___________________
___________________________________________________________________________________
Where in your body to you store or carry stress? _____________________________________________
Are you working with other physical or mental health professionals on a regular basis?
__________________________________________________________________________________
Please check any that apply
o Headaches                  o Vision problems               o Sinus problems                o Jaw pain/teeth grinding
o Fatigue                        o Depression                        o Sleep problems                o Numbness/tingling
o Blood clots                 o Scoliosis                            o Arthritis                            o Tendonitis
o Lymph conditions     o Osteoporosis                    o Varicose veins                 o High/low blood pressure
o Muscle/joint pain      o Diabetes                            o Cancer/tumors                 o Infectious disease
o HIV/AIDS
List any major illnesses, hospitalizations, surgeries, etc, with dates. Please include car accidents.
___________________________________________________________________________________
___________________________________________________________________________________
Have you healed fully from these? _______________________________________________________
What kind and frequency of exercise do you do? Do you participate in any sports?
___________________________________________________________________________________
___________________________________________________________________________________
What is your occupation? ______________________________________________________________
Please circle all of these that you do for your job:
Standing – Sitting Still – Hold a Phone – Drive – Use a Computer – Perform Repetitive Motions
Have you received massage therapy or bodywork before? ______What types? ______________________
How often? ______________________ When was your last session? ____________________________
Is there any part of your body you would like me to avoid working on? ____________________________
Is there anything else I should know before we begin?
__________________________________________________________________________________
This health history is complete to the best of my knowledge. I understand that my massage therapist 
cannot take into account any conditions I do not inform her of.
Signature: ______________________________________________ Date: __________