Health History Form

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Health History Form

Email *

First and Last Name *

Preferred Pronouns

Date of Birth *

YYYY

Please select all that apply. *

Cardiovascular Issues

Nervous System Issues

Respiratory Issues (asthma, scarring, thin tissue, etc.)

Autoimmune Disorders/Diseases

Cancer

Circulatory/Lymphatic Issues (edema, anemia, etc.)

History of Fainting

History of Vertigo

Mood Issues (irritability, stress, anxiety, depression, etc.)

Poor Sleep Quality

Current Pregnancy

Recent Surgery

Past or Present Musculoskeletal Injuries (breaks, sprains, tears, etc.)

Chronic Pain (lasting more than 3 weeks)

Acute Pain (less than 3 weeks)

Chronic Tension (lasting more than 3 weeks)

Acute Tension (less than 3 weeks)

Headaches

Joint Issues (arthritis, hypermobility, stiffness, etc.)

Restricted Range of Motion

Sensation Issues (numbness, tingling, decreased feeling, etc.)

Skin Issues (psoriasis, acne, easy bruising, etc.)

Allergy to Grapeseed Oil

Required

If you selected anything from the above list, please give a detailed accounting of the selected issues including any medications, procedures, or alternative therapies being used in treatment. If you selected "other", please clarify. *

Please carefully read and select accordingly from the below options. *

I have cancer currently and am undergoing treatment.

I have cancer currently, but am not undergoing treatment.

I have had cancer in the past, but do not currently.

I have had testing for cancer done, but cancer was not found.

I have never had cancer or testing for cancer (skip next question).

If you selected any of the first 4 options from the previous question, please detail what testing was done and what treatment (if any) was administered.

What were your past experiences with massage (if any) like? What goals are you hoping to achieve with massage?
*

Lastly, if you are a new client please list the name of the person who referred you. This can be someone who told you of Body + Mind via word of mouth or through sharing my website or Facebook page. Referral is required for new clients.

Send me a copy of my responses.

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