Health History
Please fill out this medical history questionnaire before your appointment. Fully listing medications and other health info helps us to keep you safe and comfortable during your session. Even if you do not think the info is relevant to massage or other services offered, having a full picture of your health is the safest and easiest way to ensure we are aware of any potential contraindications or adjustments that need to be made to your session.
Full Name *
Your answer
Date of Birth *
MM
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DD
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YYYY
Do you have an autoimmune disease or inflammatory condition?
Do you have a history of trauma or PTSD that may affect your massage session?
Your answer
Check any respiratory health conditions that apply:
Check any cardiovascular health conditions that apply:
Check any skin conditions that apply
Check any head/neck conditions that apply:
Check any infectious conditions that apply:
Female-bodied clients- Please check conditions that apply:
Check any relevant soft tissue or joint dysfunction conditions:
Check any relevant neurological conditions that apply:
Please check other relevant conditions that apply:
If you selected "other" on the questions above, please provide additional info:
Your answer
Have you ever had any major car wrecks or accidents that resulted in whiplash? Did you receive treatment at the time?
Your answer
Have you had any surgeries or invasive procedures? If so, when? Do you have any ongoing symptoms as a result?
Your answer
Please list all medications and supplements (including medical marijuana) you are currently taking (some medications can affect your massage experience. Your therapist needs this info to make sure you stay safe and comfortable during and after your session):
Your answer
I have provided a full and accurate disclosure of my health information and current medications. I agree to update my therapist with any updates or changes in my health information before my treatment takes place in order to ensure my safety and comfort. *
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