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Ross Banerjee, Registered Massage Therapist
Health History Form

Massage Therapy is the manipulation of the soft tissues of the body to gain a therapeutic response. Soft tissues include muscles, tendons, ligaments, and fascia.

When you're in the room with Ross, you are the boss. This means that at all times you are the one who is in control and one who is most comfortable. If he does, says, looks like, or smells like anything you are not comfortable with, please let him know. He will ask you, from time to time, if you are comfortable, but on occasion, things may come up that neither he nor you expect, that require attention. Please let him know, as his ability to read minds is not what it once was … if it ever was.

In order to relieve pain, it may be necessary to recreate some of the pain you walked in with. However, Ross does not want to recreate so much pain that you will be hurt or bruised as a result of the treatment. So, he likes to use a pain scale between 1 and 10. One is virtually nothing; ten is passing out. At 5/10, you begin to hold your breath in an uncontrollable manner. If this happens, the treatment is too deep, and you must tell him to modify his treatment so that you will feel less than that 5 out of 10 pain level. This lower pain level will still treat the sore spot, however it will take longer to treat, but the end result should be that your pain disappears for longer without the annoying side effects of soreness after the massage.

During this first visit, you will be asked for a confidential health history. According to the relevant privacy laws, all health information shall be stored in a locked cabinet and shall not be shared with anyone, unless you give specific permission.

When you're getting on the table, please note, Ross does doesn't care whether you wear all your clothes or not. Massage does work best skin on skin, but massage also works best when you are comfortable, so if you are not comfortable disrobing, then you are under no obligation to do so. While under the sheets, Ross will only undrape (uncover) the areas he is working on, and only uncover them to your comfort level. If, during the course of the treatment, you feel uncomfortable with the level or style of draping, please tell Ross.

On the table, or on the chair, Ross will perform Swedish, fascial, trigger point, and a variety of other techniques, depending upon your needs.

In between sessions, sometimes Ross will offer instruction on remedial exercises. These exercises or stretches will be specifically chosen to help you to keep you as limber and pain free as possible. You live in your body 24 hours a day, 7 days a week, whereas Ross may only be working on you once, twice, thrice, or less or more times per month, for about an hour at a time. This means that while you know yourself better than Ross does, a single massage can only be so helpful. Your exercises and stretching will go a long way to ensuring that the massage, or massages, will be as effective as possible, in the long run.

Rates - HST 84636 9759 RT0001 *
Your answer
Massage Duration and cost *
On a scale of 1-10, where 10 is passing out, what is your pain level today?
Virtually Nothing
Passing out
Musculoskeletal System: What hurts?
Circulatory System: What is your history?
Nervous System: What is your history?
Skin Conditions: What is your history?
Digestive Conditions: What is your history?
Immune System: What is your history?
Women only
Other concerns
Other concerns
Your answer
What is your main complaint
Are you seeing any other health care practitioner?
How effective is the treatment?
Not Effective
Very Effective
How much recreational activity do you do?
What exercises do you do?
Your answer
Your answer
Phone (home)
Your answer
Phone (work)
Your answer
Phone (mobile)
Your answer
Your answer
Your answer
Date of Birth
Doctor's Name
Your answer
Client Agreement and Declaration *
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